Malaria in Bangladesh

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British Library Cataloguing in Publication Information Available Library of Congress Cataloging-in-Publication Data Names: Singer, Merrill, author.

Title: Introducing medical anthropology : a discipline in action / Merri\ ll Singer, University of Connecticut, Hans A. Baer, University of Melbourne, Debbi Long, RMIT Uni\ versity, Alex Pavlotski, Aukland University.

Description: Third Edition. | Lanham : ROWMAN & LITTLEFIELD, [2019] | “Second edition 2012”—T.p. verso. | Includes bibliographical re\ ferences and index. | Identifiers: LCCN 2018048811 (print) | LCCN 2018051819 (ebook) | I\ SBN 9781538106471 (electronic) | ISBN 9781538106457 (cloth : alk. paper) | ISBN 978153\ 8106464 (paper : alk. paper) Subjects: LCSH: Medical anthropology.

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Printed in the United States of America Preface ix About the Authors xi 1 Introduction to the Anthropology of Health 1 Introduction and Overview 1 Encountering Health Anthropology 1 Three Case Studies in Applied Health Anthropology 2 Coping with Cystic Fibrosis 2 The Bone Crusher 3 Pesticide Poisoning 5 Practical and Theoretical Contributions of Health Anthropology 8 Clarifying the Culture of Health and Illness 8 Health Inequality 9 Defining Health Anthropology 10 Culture and Biology 10 History of Health Anthropology 12 The Straits Expedition 12 W. H. R. Rivers and Beyond 14 Rudolf Virchow 15 Er win Ackerknecht and William Caudill 15 The Postwar Period 15 Health Anthropology and National Development 16 The Discipline Is Born 16 The Relationship of Health Anthropology to Anthropology and to Other Health-Related Disciplines 17 Health Research and the Subfields of Anthropology 17 Health Anthropology and Epidemiology 20 Illness and Help-Seeking Behavior 24 Health Anthropology and Public Health 24 Health Anthropology and Bioethics 31 Health Anthropology Theories 32 Medical Ecology 32 Meaning-Centered Health Anthropology 33 Critical Health Anthropology 34 2 What Health Anthropologists Do 37 Introduction and Overview 37 Contents iii iv Contents Three Settings, Three Case Studies, Three Health Anthropologists 37 Life and Death in Tanala 37 Studying Surgeons 39 Folk Illness in Haiti 41 A Case Study 43 Having Impact 43 What Health Anthropologists Study 44 A Diverse Discipline 44 Studying the Life Course 46 Conducting Research: A Peculiarly Anthropological Approach 49 Holistic, Field-Based Understanding 49 Ethnography 49 Complex Sociocultural Tapestries 52 Research Methods 54 Multimethod Research 54 Examining Lives 55 Focus Group Inter views 56 Considering Consensus 57 Doing Diaries 57 Quantitative Methods 58 Broader Collaboration 59 Health Anthropology in Use 59 Mobilizing Research Findings 59 The Health Anthropology Crystal Ball 61 3 Understanding Health, Illness, and Disease 65 Introduction and Overview 65 Conceptions of Health and Illness 65 Defining Terms 65 Differentiating Disease and Illness 66 Reconceptualizing Disease and Illness 69 Understanding Cure 69 Folk Understandings 70 Understandings of Disease Causation 71 Humanizing Biomedicine 73 Sufferer Experience 73 Experience and Cultural Symbols 73 Cultural Emotions 74 Social Suffering 76 Beyond Social Suffering 77 Disability and Chronic Illness 78 The Patient in the Body 78 The Cultural Construction of Disability 79 Contents v Stigmatization 82 Human Rights and Health 83 Illness Narratives 85 The Social Uses of Narration 86 Analyzing Narrative 86 Embodied Health Experience 88 Why Bodies? 88 Body Theor y 89 Bodies in the Age of Immunology 90 Cyborg Bodies 91 Mindful Bodies 92 Engendered Bodies 95 Understanding Medicalization 95 Healer versus Sufferer Conception of Disease 96 The Two Sides of Compliance 96 Insider and Outsider Assessments of Health Status 98 One Word, Two Meanings 98 Diseased but Not Ill 99 Mismessaging 99 Analyzing Health Discourse 100 4 Health Disparity, Health Inequality 102 Introduction and Overview 102 What Is Health Disparity? 102 Health Disparity in the United States 103 Gasping for Breath 104 Causes of Health Disparity: Lifestyle versus Social Inequality 106 Living Right 106 Structural Explanation 106 Biology of Poverty 108 Insuring Disease 109 Culturally Competent Care 110 Health and Social Disparities Cross-Culturally 113 Child and Maternal Health Disparities 116 Addressing Health Disparities 121 Addressing Health Disparities in the Community 121 Upstream Analyses of Health Disparities 122 Gender and Global Health 124 Focusing on Disparity in Diseases 125 Multidisciplinar y Approaches 126 Studying Local Mediation of Global Health 126 vi Contents Pushing Back on Health Disparities 128 “Race” and Health Disparity 128 Race and Racism 129 5 Health and the Environment: Toward a Healthier World 131 Introduction and Overview 131 Medical Ecology and Critical Health Anthropology on the Environment 132 Health and the Environment in the Past 134 Health and the Environment Today 136 Depletion of Natural Resources and Environmental Degradation 137 Capitalism and Climate Change 139 Infectious Diseases in a Globalizing World 140 The Impact of Climate Change on Health 141 Other Environmental Impacts on Health 145 Water and Globalization 146 The Political Ecology of Cancer 148 Cancer in the Community 149 Cancer and Industr y 150 China’s Cancer Villages 151 Anthropological Examinations of Cancer Treatment 152 Nuclear Reactors and Health 152 Unconventional Natural Gas Extraction and Health 153 The Impact of Private Motor Vehicles on Health 154 The Political Ecology of AIDS: Assessing a Contemporary Syndemic 155 6 Ethnomedicine: The Worlds of Treatment and Healing 159 Introduction and Overview 159 Approaching Ethnomedicine 159 Indigenous and Folk Medicine Systems 162 Ways of Healing 162 Typologies of Healing Systems 163 An Evolutionary Model of Disease Theories and Healing Systems 165 Health, Illness, and Medicine in Family-Level Foraging Societies 166 Health, Illness, and Medicine in Village-Level Societies 169 Health, Illness, and Medicine in Pastoralist Societies 170 Health, Illness, and Medicine in Chiefdom Societies 171 Contents vii Folk Healers in Modern Societies 171 Case Study: Are the Therapeutic Aspects of Religion Something That Partially Address Refugee Health Problems? 173 Biomedicine as the Predominant Ethnomedicine in Modern Societies 175 Hospitals 176 Health Anthropology and the Pharmaceutical Industr y 178 7 Plural Medical Systems: Complexity, Complementarity, and Conflict 182 Introduction and Overview 182 A Case Study of Medical Pluralism in a Rural Area in a Developing Society: The Altiplano of Bolivia 183 Themes 183 Medical Subsystems 184 Status of Health Care in Bolivia in the Pre-Revolutionar y Era 184 Social and Health Conditions in Bolivia after the Election of Indigenous\ President Evo Morales 185 A Case Study of Medical Pluralism in an Urban Setting of a Developing Society: A View from Central Java 188 Medical Subsystems 188 A Case Study of Medical Pluralism in a Developed Society: The Australian Dominative Medical System 190 Medical Subsystems 190 Typologies of Plural Medical Systems 195 Healing and Histor y 196 Patients of CAM 199 CAM and Class 201 New Directions in the Study of Medical Pluralism 207 Medical Syncretism 208 Medical Diversity 209 Medicoscapes 210 The Globalization of Traditional Medicine and CAM 210 8 The Biopolitics of Life: Biotechnology, Biocapital, and Bioethics 212 Introduction and Overview 212 Critical Health Anthropology and Biotechnology 212 Science, Nature, and Culture 213 Biocapital: Bodies of Profit 215 viii Contents Reproductive Technologies 216 Divisible Bodies 220 Bringing the Lab into the Field: Anthropology and the Neurosciences 222 Molecular Biotechnologies: Tiny Pieces, Giant Infrastructures 224 The Story of hGH—Growing up Growth Hormone 227 The Culture of PCR 228 Visualization Technologies 229 When Technologies Combine 230 Ancestry, Families, and Genetics: Biotechnology and Belonging 233 9 Strategies and Visions for a Healthier World 240 Introduction and Overview 240 Global Capitalism 240 Democratic Eco-Socialism as a Pathway for a Healthier World 242 Health Anthropology as an Action-Oriented Endeavor 247 Source Material for Students 251 Glossary 255 References 260 Index 300 Students often do not bother with the prefaces to assigned textbooks, an\ d for understandable reasons. The comments of authors about their book are not\ going to be on any test and it is the contents of the book, its ideas, c\ oncepts, theory, and examples, not the book as a product of author labor or the g\ oals and intentions of authors, that is of most immediate concern to the student \ reader.

We hope, in this instance, that these remarks capture some student attention because they deal with an important conceptual issue and provide a glimp\ se behind the curtain of book publishing. When the first (2007) and sec\ ond (2012) editions of this book were published, the authors recognized that while medical anthropology was not the most fitting name for the field our book wa\ s introduc- ing to students, it was the established and widely accepted term. Indeed\ , medical anthropology was a label that smuggled in a lot of problematic baggage. \ Since the last edition, however, our discomfort grew to the point that in 2016\ , along with our colleagues Debbi Long and Pamela Erickson, we published a paper\ in a leading anthropology journal entitled “Rebranding Our Field: Tow\ ards an Articulation of Health Anthropology.” We feel strongly that the time \ has come to retitle medical anthropology using a more appropriate label that bett\ er reflects conceptual developments in the field. Our subfield, as shown clearly\ in the chap- ters of this book, has a wide range of concerns that includes a keen foc\ us on biomedicine and other ethnomedical and health-care traditions. But the w\ ork of those we have come to call “medical anthropologists” addresses mul\ tiple other issues that are not specific to medicine or healing, including underst\ anding health and illness within society and within the complex social and political-e\ conomic systems created by globalization. Consequently, we proposed the name “\ health anthropology”; this better describes the core issue that unites the s\ ubfield.

We called for dropping the term medical anthropology because, as has lon\ g been recognized by many in the field, it is limiting and misleading, and re\ flects the hegemony of biomedicine at various levels. This renaming does not preclu\ de health anthropologists working on or within biomedical, complementary, and alternative medical or indigenous medical settings, as reflected in th\ e fieldwork of all of the coauthors of this book. It was our intention, however, that i\ n its third edition this book be renamed Introducing Health Anthropology: A Discipline in Action to reflect the true breadth of the field. This is where good intentions ran into marketing realities. Our book, and its title, were known, and Introducing Medical Anthropology was widely used as a textbook, the second-best-selling core text on the market in our topical niche.

In our publisher’s reasonable approach to their business it was not s\ een as a good idea to change the title of an established text. The book was seen \ as having instant name recognition for professors who might assign it in a class. \ Changing the title, the publisher felt, could cause confusion to teachers and to \ bookstores looking to order books for classes. As one reviewer of our proposed name\ change commented, “Why not continue to use it as a marketing tool to appeal to the Preface ix x Preface widest number of folks?” For these reasons, the title has not changed\ in the third edition, but the text has been updated to reflect our concerns on this\ matter.

Throughout this text, if not on the cover, we use the terms “health a\ nthropol- ogy,” “health-oriented anthropology,” and “health anthropolo\ gists.” One thing that has changed is the addition of Debbi Long and Alex Pavlotski as coauthors, which, based on their areas of expertise and fi\ eldwork experience, allow us to further examine the wide range of issues investi\ gated in a health-oriented anthropology. One of the goals of the third edition of this book is to affirm that health-oriented anthropologists are very involved in the process of help\ ing, to varying degrees, to change the world around them through their work in a\ pplied projects, policy initiatives, and advocacy. Not all anthropologists teac\ h in a col- lege or university—many are involved full time in directly applied wo\ rk—and most who do teach medical anthropology courses are involved in applicati\ on.

Moreover, as the landscape of academia endures major transformations, wi\ th underpaid adjunct labor now increasingly replacing stable faculty positi\ ons, anthropologists must find creative ways to bring their skill-sets out \ of the ivory tower and into the world. Our subdiscipline both addresses specific he\ alth issues and analyzes them in their broader context. In other words, we seek to u\ nder- stand health-related issues and to use this knowledge in improving human\ health and social well-being. A second goal of this book is a presentation of the fundamental importan\ ce of culture and social relationships in health and illness. Through a rev\ iew of the key ideas, concepts, methods, and theoretical frameworks that guide rese\ arch and application in health-oriented anthropology, the book makes the case\ that illness and disease involve complex biosocial processes and that resolvi\ ng them requires attention to a range of factors beyond biology, including local\ systems of belief, structures of (often unequal) social relationship, the deve\ lopment and globalization of new technologies, and environmental and climatic condit\ ions. Finally, through an examination of the issue of health inequality, such \ as exposure to pesticides among farmworkers, unequal access to health care,\ the role of poverty in the spread of disease, or environmental degradation a\ nd envi- ronment-related illness, this book underlines the need for an analysis t\ hat moves beyond cultural or even ecological models of health toward a comprehensi\ ve biosocial approach. Such an approach integrates biological, cultural, and social factors in building unified theoretical understandings of the origin o\ f ill health, while contributing to the building of effective and equitable national h\ ealth-care systems. In this manner, health anthropologists have a broad vision of p\ lanetary health and seek to be part of a collective process aimed at creating a healthier world for both humanity and the biosphere. The ultimate goal is prevaili\ ng over the social causes of disease, the structures of social injustice th\ at diminish well-being, and the social forces driving environmental destruction, inc\ luding human-created or anthropogenic climate change. For us, ultimately, bring\ ing these issues into the classroom, especially in a time when health has be\ come a daily issue of deep concern, is of far greater importance than the speci\ fic way the field is labeled. Merrill Singer is professor in the Departments of Anthropology and Com- munity Medicine at the University of Connecticut. Dr. Singer has publish\ ed 290 scholarly articles in peer-reviewed journals and book chapters, and \ has authored, co-authored or edited thirty-three books. His research and writing have addressed syndemics, HIV/AIDS and STDs in highly vulnerable and dis\ ad- vantaged populations, illicit drug use and drinking behavior, infectious disease, community and structural violence, and the political ecology of health, \ including the health consequences of climate change. Dr. Singer has been awarded t\ he Rudolph Virchow Professional Prize, the George Foster Memorial Award for\ Practicing Anthropology, both the AIDS and Anthropology Research Group’\ s Distinguished Service Award and its Clark Taylor Professional Paper Priz\ e, the Prize for Distinguished Achievement in the Critical Study of North Ameri\ ca, and the Solon T. Kimball Award for Public and Applied Anthropology from \ the American Anthropological Association.

Hans A. Baer is Principal Honorary Research Fellow in the School of Social Political Sciences at the University of Melbourne. He has published twen\ ty-one books and some 190 book chapters and articles on a diversity of research\ top- ics, including Mormonism, African American religion, sociopolitical life\ in East Germany, critical health anthropology, medical pluralism in the United S\ tates, United Kingdom, and Australia, the critical anthropology of climate chan\ ge, and Australian climate politics. His most recent books are Democratic Eco-Socialism as a Real Utopia (2018), and Urban Eco-Communities in Australia: Real Utopias or Market Niches? (with Liam Cooper, 2018).

Debbi Long is senior lecturer in global studies at RMIT University (Melbourne, Australia). She is a critical health anthropologist and a pioneer of ho\ spital eth- nography in Australia. She is an experienced health ethnographer, having\ under- taken fieldwork in Turkey, Swaziland (eSwatini), and in a variety of\ contexts in Australian public hospitals, including maternity, spinal, intensive care\ , and dialy- sis units. She has worked as a consultant in clinical organization and m\ anagement on projects including quality improvement, patient safety, behavior change, and in industrial relations contexts. Recent research has included family vi\ olence education and compensation industry analysis. She has taught at undergra\ duate and postgraduate levels in anthropology departments; international development programs; medical, nursing, and allied health programs; and in indigenou\ s foun- dation and support programs.

Alex Pavlotski is teaching fellow at Auckland University, New Zealand, and an honorary research fellow at Latrobe University in Australia. He is an\ anthro- pologist and graphic artist. Alex has conducted fieldwork with comic a\ rtists in About the Authors xi xii About the Authors Japan, and in Australia with an urban LGBTQI+ community; with CEOs and accountants across the country; and with recipients of government disabi\ lity payments. His PhD thesis was on the global movement subculture of parkou\ r, a multisited ethnography undertaken across twenty-four cities in eight n\ ations.

His research interests are psychological and neuroanthropology, visual r\ epresen- tation in ethnography, cross-cultural communication, masculinity in lead\ ership research, organizational ethnography, systems design, mind-body connecti\ vity, and reactionary identities. 1 1 Healing requires a legitimated, credible and culturally appropriate syst\ em. —Mildred Blaxter (2004:43) Introduction and Overview I n this chapter, we begin the process of defining and differentiating hea\ lth an- thropology in light of the range of disciplines concerned with health. W\ e initi- ate this introduction to health anthropology by presenting three case st\ udies. We then address both the practical and theoretical work and contributions o\ f health anthropology, differentiate health and illness as technical terms in the\ discipline, engage the issue of health inequality, review the history of health anthropology, and compare and contrast health anthropology with other health-related fields including discussion of multidisciplinary collaboration. Encountering Health Anthropology People who encounter the term medical anthropology, or, as explained in the preface, “health anthropology,” for the first time often are puz\ zled by what it means. Is it the study of how medicine is practiced, what doctors, nurse\ s, or traditional healers from other health-care systems actually do? Or is it\ the study of what it means and feels like to be sick? Perhaps it is the study of f\ olk illnesses in different societies? Might it be the application of cultural knowledg\ e to the actual treatment of diseases? All these questions, in fact, can be answe\ red in the affirmative. Health anthropology addresses each of these issues—and\ far more.

A starting premise of health anthropology is that health-related issues,\ including disease and treatment, how and why one gets sick, and the nature of reco\ very, are far more than narrow biological phenomena. These processes are all heavi\ ly influ- enced by environmental, political-economic, social-structural, and socio\ cultural factors as well. Consequently, health anthropology has developed a bio-sociocul- tural approach in its effort to address health as an aspect of the human condition. To take one example, health anthropologists ask questions such as the following: Could we really understand the AIDS pandemic and respond to i\ t effectively simply by studying the human immunodeficiency virus, its i\ mpact on cells of the body, and medical interventions designed to stop the vir\ us from destroying the immune system? Would we not also need to know how to reac\ h and effectively engage those who are at greatest risk for infection, to figure out the structural and situational factors that contribute to their involvem\ ent in risky behaviors, to know how much they know and what they feel about AIDS and \ how these factors influence their behaviors, and to determine whether \ the ways Introduction to the Anthropology of Health 1 CHAPTER 1 INTRODUCTION TO THE ANTHROPOLOGY OF HEALTH 2 Chapter 1 we go about interacting with them in the community and in the clinic dra\ w them closer or push them away from our treatment programs? In other words, be\ yond biology clearly there are critically important areas of knowledge in the\ ongoing fight against the now about forty-year-old AIDS epidemic. Now, if we t\ hink about the AIDS epidemic as a global problem, a global pandemic, with dif\ ferent routes of infection, different populations at risk, different beliefs an\ d behaviors associated with HIV/AIDS in diverse settings, and different health-care \ systems in different parts of the world or even different parts of a single coun\ try, we begin to get an initial sense of why a social science like anthropology \ might—as it certainly has—have a significant role to play in addressing the \ AIDS epidemic.

This is of no small importance; we know from available research that HIV\ / AIDS is destined to take a greater toll on our species, proportionately \ and in terms of absolute numbers, than the bubonic plague, smallpox, and tuberc\ ulosis combined. Consider the epidemic in South Africa, the country with the hi\ ghest burden of HIV/AIDS in the world. As Didier Fassin (2007a:261) points out, “In one decade, the rate of HIV infection went from less than 1 perce\ nt to over 25 percent of the adult population and AIDS became the main cause of dea\ th for men and women between 15 and 49 years of age,” with an expected d\ rop in average life expectancy in the country of as much as twenty years. Mo\ reover, the global pandemic has helped to shape the social, cultural, and health\ worlds of people all over the planet, whether or not they are always aware of i\ t. Within the broader story of the devastating impact of HIV/AIDS, however, there \ are many differing local narratives that together comprise the complex mosai\ c of the pandemic. The work of health anthropologists has been part of that s\ tory in many places and the same is true for a vast array of other health issues\ . Moreover, health anthropology, while sometimes contributing to cultural explanatio\ ns of HIV/AIDS risk behavior, has struggled in recent years to counter explana\ tions that fail to address the fact that the global economy or capitalism and \ social inequality are the primary driving forces in the epidemic (Hlabangane 2\ 014).      Three Case Studies in Applied Health Anthropology Coping with Cystic Fibrosis The Reynolds family has two children. Carl is five and Stuart is seven. The younger of the two boys has cystic fibrosis (CF), the most common fatal genetic disease in the United States. Cystic fibrosis causes the body to produce a thick- ened form of mucus that clogs the lungs, leading to repeated bacterial infec - tions and increasing lung damage. While the median age of survival among CF sufferers has been rising, most people with the disease do not live very far i\ nto adulthood before they succumb. Day-to-day care of a child with CF commonly falls on family members who must learn to cope with both a painful prognosis and the demands of responding to the patient’s menacing symptoms, including pounding on the sufferer’s chest and back for at least thirty-five to forty minutes Introduction to the Anthropology of Health 3 at a time, two to four times a day, to dislodge mucus. Some burdens fall partic- ularly hard on the siblings of children with CF. Deana Reynold, Stuart’s mother, notes one of these burdens that he must endure: “When Carl’s sick, all the phone calls are, ‘How’s Carl?’ Everybody who sees Stuart [says], ‘How’s your brother doing?’ And all the presents. Carl gets all the presents. It has to have some kind of effect on him [Stuart].” How (and how well) do families with a child \ with CF cope? What toll does the disease take on family relations and on the emotional well-being of family members? How are siblings affected by growing up with a chronically ill brother or sister? How can health-care providers most effectively communicate with families at various stages in the natural history of CF\ progres- sion? Having previously studied children with cancer, health anthropologist Myra Bluebond-Langner (1996) set out to answer these critically important q\ uestions.

For nineteen months, in the clinic and in their homes, she repeatedly interviewed and observed families that were recruited from the patient rolls of the Cystic Fibrosis Center of St. Christopher’s Hospital for Children in Philadelphia. She also interviewed attending physicians and reviewed patients’ medical charts.

Like most anthropologists, she immersed herself in the lifeworlds of the people she was studying. Her field notes and taped interviews filled thousands \ of pages and numerous three-ring binders. In the end, after many months of data collec- tion and careful analysis, she was able to answer the key questions that moti- vated the study. Additionally—and tellingly—she was able to use her findings to develop a set of useful guidelines for physicians to use in clinical \ intervention with families with a CF sufferer. As a result, physicians now have a clearer idea of how best to communicate with families and to assist them in coping wi\ th the difficult challenges they face and the weighty burdens they must bear. Like the work of many other health anthropologists, this work by Bluebond-Langner has helped to make a positive impact in the tangled and often confusing worl\ d of health and illness. Addressing conflicts, miscommunications, and other prob- lems in doctor-patient relationships as well as patient access to high-quality, culturally appropriate health care are central issues in health anthropology. But there are many other concerns as well.

The Bone Crusher Dengue, the most prevalent mosquito-borne viral disease on earth, is found in more than one hundred countries and territories around the world, primarily in tropical and subtropical environments of Latin America, the Caribbean, and Southeast Asia, although a U.S. outbreak occurred in Hawaii in 2001. Since then, however, locally acquired cases of dengue have begun to appear in sev- eral geographic areas in the United States and researchers fear that the disease could be gaining a significant foothold on the U.S. mainland.

Current estimates are that each year fifty million to one hundred million peo- ple are infected with dengue when they are bitten by either the Aedes aegypti, the mosquito that also transmits yellow fever, or Aedes albopictus mosquitoes. 4 Chapter 1 Mosquitoes become infected when they bite people who are infected, and, in turn, they subsequently transmit the infection to other people that they bite. In Southeast Asia and in most of Latin America and the Caribbean, the disease is pandemic, meaning that it is now firmly entrenched in the population and spreading. Malaysia has been particularly hard hit; thousands of people fall vic- tim each year to this disease colloquially known—because of the fears\ ome joint pain it causes—as the “bone crusher.” Other symptoms include stomach pain, headaches, nausea and vomiting, pain behind the eyes, and body flushes. \ In a more intense and even more frightening form, known as hemorrhagic fever, the sufferer’s gums, nose, and internal organs bleed.

A number of health anthropologists have worked on preventing the spread of dengue. Karl Kendall (1998), for example, developed a strategy that\ involves studying and utilizing local health beliefs and practices in the develop\ ment of community health campaigns about dengue in El Progreso, Honduras. In Kendall’s approach, the first step in raising community awareness of effective prevention involved conducting in-depth interviews and surveys with commun\ ity members to assess what they think and believe about dengue, its routes of infection, and the strategies they use to prevent becoming sick with the dreaded disease. This information was used to frame a locally meaningful educati\ on campaign designed to raise community awareness of the insects that transmit dengue, including effective pest control measures. This culturally sensitive proj- ect proved to be effective in reducing the populations of dengue-carrying mos- quitoes, lowering rates of infection.

Sara Crabtree and colleagues (2001) built on this approach in the prevention of dengue in two communities in Malaysia. Like Kendall, Crabtree and coworkers began their work with a study of community knowledge, attitudes, and beh\ aviors related to the disease. They also conducted focus groups with four different sub- groups—women, youth, men who were heads of families, and village leaders—in an area that had not yet been hard hit by dengue. Through this research, it was found that the communities lacked much awareness of mosquito-borne disease transmission; they did not associate getting sick with being bitten by m\ osquitoes.

Consequently, while they were available, people did not make much use of mos- quito nets or spray repellents. The team then organized a set of three-day work- shops designed to train volunteers to conduct a needs assessment on how to prevent dengue in their local communities. Under the guidance of the researchers, these individuals then carried out a door-to-door survey in their local communi- ties. Researchers then worked with the needs assessment staff in translating find- ings into a strategic set of recommendations for practical, achievable activities to reduce mosquito populations. With the support of local leaders, actions based on these recommendations, such as burning accumulated rubbish, cleaning water containers, and identifying and eliminating breeding sites, were implemented to lower mosquito populations, a goal that was achieved in both participati\ ng com- munities. The health anthropologists involved in this project believed that this Introduction to the Anthropology of Health 5 success was due in large part to the initial assessment to ascertain com\ munity concerns, mobilize locally generated prevention ideas, and involve community members in all phases of the prevention initiative.

Despite the efforts described here, dengue continues to spread in the world, as do a range of old, new, and renewed diseases that were once controlled but are again spreading out of control (see chapter 6). From the fight against AIDS to the reduction of sexually transmitted diseases, health anthropologists, with their unique approach to understanding health and disease in terms of the interaction of human biology with social and cultural factors, are often on the front lines of infectious and other disease prevention as well as of the development of cul- turally and structurally appropriate and hence often more effective approaches to care. Although not all health anthropology projects are effective and success might be achieved at a much lower level of effect than would be desired, health anthropologists can point to a strong track record of making useful contributions to improving health, usually at the local level but sometimes even more broadly.

In no small part, this is because a core realization of health anthropology is that disease vulnerability, including vulnerability to dengue, “is a relationship. It is always dependent upon cultural, social, and economic factors” (Nadin\ g 2017).

Pesticide Poisoning The World Health Organization, a technical agency of the United Nations, esti\ - mates that there are more than a billion agricultural workers in the world, most in developing countries. Ethnographic research on the health of agricultural workers—specifically workers who work the fields by hands—are subject to “segregation . . . into a hierarchy of perceived ethnicity and citizenship” that pro- duces significant social and economic inequality and leads to “displa\ cement, migration, sickness, and suffering” (Holmes 2013:182). In the world inhabited by agricultural workers, their immediate supervisors, land owners, policy makers, and the wider society, the social and health inequalities suffered by agricultural workers are “considered normal, natural, and justified” (Holmes 2013:182) by ideologies of racialized biology. Rather than the consequences of unjust govern- ment policies that allow very low wages and limited occupational health \ protec- tions, exploitation by employers who are dependent on very cheap labor for their profits, and a health-care system that, by blaming workers’ culture and behavior rather than structural factors for their health problems, becomes inadvertently complicit in the functioning of a harmful social order.

Various studies have shown that one of the health problems commonly faced by agricultural workers is poisoning due to exposure to dangerous pesticides; indeed, they are the sector of society most likely to suffer health consequences from the powerful commercial poisons sprayed on food and ornamental crops to limit plant pests. Not only are those who work in agriculture at risk, but so are their spouses and children. Poisoning occurs because pesticide sprays are caught in the wind and drift into adjacent fields where people are working or into areas where 6 Chapter 1 they and their families live, because workers are sent to work in fields in which pes- ticide has recently been applied, and because workers pick up pesticides on their clothing and other possessions, including their food containers, and bri\ ng them home unaware of potential risk. Even if exposures are limited, pesticides accu- mulate in the body, so that repeated contact increases risk for health-threatening outcomes. One of the most commonly used groups of pesticides, organophos- phates (OPs), can be taken into the body through breathing, through ingestion, and through skin exposure. Organophosphates are known to damage nerves by reducing the availability of acetylcholinesterase, a necessary enzyme fou\ nd at nerve endings. Organophosphate poisoning can produce rashes, nausea and vomiting, body fatigue, loss of consciousness, shock, and even death.

One OP pesticide, chlorpyrifos, has the distinction of being a neurotoxin that has been shown to be particularly dangerous to infants and young children.

Approximately five to ten million pounds of the chemical, most of it produced by Dow AgroSciences, are applied to agricultural crops in the United States annu- ally. A review of the pesticide by Environmental Protection Agency researchers during the Obama administration led to a recommendation that, given the threat it posed to children, chlorpyrifos be banned. The review found that residues of chlorpyrifos on food crops exceed existing safety standards and that drinking water exposure to the pesticide also exceeds safe levels. With the election of the Trump administration in 2016 and the subsequent appointment of an unabash - edly probusiness and antiregulatory advocate, Scott Pruitt, to head the agency, the decision was made not to ban the pesticide. Opponents of the decisio\ n, health anthropologists among them, assert that the job of the agency, which increasingly has adopted a position of regulatory laxity, is to protect the health and safety of people, not the profits of corporations (Kolbert 2017).

Existing protections for farmworker health are limited. In 2002, for exam - ple, the Pesticide Action Network North America and a group of collaborating organizations issued a report called Fields of Poison based on data on pesti- cide poisoning collected by the California Department of Pesticide Regulation.

The report found that farmworkers face a two-sided threat from pesticides: first, the existing set of regulations designed to protect them from harmful exposure to toxic chemicals is woefully inadequate to really provide safeguards against acute pesticide exposure, and, second, even the existing laws are weakly enforced. To address this issue, Thomas Arcury, Sara Quandt, and a team of colleagues (2005) recruited a group of nine farmworker households in North Carolina and Virginia for participation in an intervention study called ¡La Familia\ !

Reducing Farmworker Pesticide Exposure, funded by the National Institute of Environmental Health Sciences. The research team conducted in-depth interviews with agricultural landowners and agricultural extension worke\ rs, com- pleted interviews on beliefs about pesticide exposure and safety among primar - ily Latino farmworkers, collected samples in the homes of farmworkers to detect the presence of OP pesticides on household furnishings, and carried out urine Introduction to the Anthropology of Health 7 tests of farmworker adults and their children to assess body metabolite levels, which reveal whether OPs are present in the bodies of study participants.

These researchers found high levels of OP metabolites, which are the by-products of OP exposure, in the members of all of the households they stud- ied, and all households had at least one member with especially high lev\ els.

Moreover, families that had carpeted homes but lacked a vacuum cleaner had higher-than-average OP metabolite levels. Bathing patterns also were linked to OP metabolite levels. As a result of their findings, this research team was able to iden- tify specific policy changes that were needed to reduce farmworker exposure to OPs, including ensuring that all rented farmworker dwellings have shower facilities and working vacuum cleaners, that all farmworker dwellings are built at a safe dis- tance from agricultural fields, and that all farmworkers receive training in pesticide risks and handling. Reflecting on the ultimate goals of their study, they conclude, Providing farmworker families (as well as all Americans) with safe and a\ ffordable housing will reduce their exposure to pesticides. This is not an instance of “blaming the victim” for exposure to pesticides, and attempting to address a systematic health disparity by educating those exposed to pesticides. Rather, it is an effort to build the capacity of farmworkers to defend themselves and to demand safe housing for their children. (Arcury et al. 2005:50) Notably, most farmworkers live in countries with far fewer resources and weaker laws to protect workers than is the case in the United States. Pesticides produced in the United States, however, are shipped around the world, and anthropologists have observed them being applied by hand by workers who had received little or no information about how deadly they can be if not han\ dled properly. For health anthropologists who work with agricultural populations, there is much work to do to help them protect themselves from occupational threats to their lives and well-being. In this instance, part of the problem is social inequality and the prevailing structure of power relations in society, such as the making and enforcing of laws that favor one social class, ethnic group, or gender over another. Indeed, health anthropologists have found that social relationships, such as those between ethnic groups, and social structures that determine access to resources and other things of value are a fundamental factor in health generally.

Although pesticide poisoning is a significant threat to the health of farmwork- ers, it is neither the only one nor the only one that has been effectively studied by health anthropologists. For example, Sarah Horton and Judith Barker (2010) have examined the issue of severe dental caries among the children of farm- workers in the Central Valley of California. They report that poor early oral health can have enduring effects both on children’s physical development, including malformation of oral arches and crooked adult teeth, and on their emotional development, as a result of social stigmatization as young adults. This research examined the role played by inadequate diet as well as other anthropogenic environmental factors in the development of what they refer to as stigmatized 8 Chapter 1 biologies. For example, these researchers present the case of Jorge, a young man who has “borne the marks of his lack of insurance as a child all his life. A star athlete and popular high school senior, Jorge feels his one social vulnerabil- ity is his stained and crooked smile” (Horton and Barker 2010:213).

Moreover, they reveal how market-based dental health insurance sys- tems—and lack of access to insurance coverage among many farmworkers—\ contribute to enduring negative health effects. For this analysis, they use Margaret Lock’s concept of local biology and recognition of the plasticity of biol- ogy to show how biology, rather than being a static or uniform phenomenon, in fact differs across groups as a result of factors like culture, diet, and the impress of a human-made environment and as consequence of differential social access to prevention care and treatment. Thus, they argue that market-based health- care systems create embodied differences between groups of people in society that both reflect and reproduce a structure of social inequality. Investigations of this sort affirm the value of a bio-sociocultural model in health anthropology.      Practical and Theoretical Contributions of Health Anthropology The cases described here suggest an answer to the question, “why have\ a health anthropology?” The answer is this: because health anthropologists, us\ ing anthro- pology’s traditional immersion methods for studying human life up clo\ se and in context, as well as the discipline’s holistic picture of the human si\ tuation, a tradi- tional disciplinary concern with understanding things from the insider’\ s point of view and flow of experience, and an applied orientation to human probl\ ems, can make an important difference in the world. Revealing the nature of this \ difference is, as noted in this chapter, one of the main goals of this book. While a primary emphasis of this book is on the practical contributions \ of health anthropology, the theoretical contributions of the discipline are equally important and guide the application of health anthropology in addressing\ par- ticular health-related issues. Theory in health anthropology addresses q\ uestions such as the following: What determines health and illness? How and why d\ o societies vary in their health-care systems, illness beliefs, and illnes\ s experiences?

What role does culture play in treatment outcome? These questions are al\ so addressed in this book.

Clarifying the Culture of Health and Illness Beyond its initial goal, a second goal of this book is a presentation of\ the fun- damental importance of culture and social relationships in health and il\ lness.

Through a review of the key ideas, concepts, methods, and theoretical fr\ ame- works that guide research and application in health anthropology, the bo\ ok Introduction to the Anthropology of Health 9 makes the case that illness and disease involve complex biosocial proces\ ses and that resolving them requires attention to a range of factors beyond biol\ ogy, including systems of belief, structures of (often unequal) social rela\ tionship, and environmental conditions. Culture is a concept that has been central to anthropology throughout its 130-or-so-year history. In the past, anthropologists tended to think of \ culture as an established pattern of influential beliefs, practices, norms, an\ d values that were shared in a social group and passed down and learned across generations to create unique configurations, the kind of differences among the ways o\ f life and temperaments of people travelers report as they visit different destinat\ ions. These differences are found not only in behavior and ideas, but also in the wa\ ys people perceive and organize their worlds, their symbols, their sense of normal\ or proper behavior, and much more. Over time, the somewhat fixed view of culture described above gave way\ to a more processual understanding of culture as an existing, discernable str\ ucture but one that is continually remade, rethought, and reinforced through social\ inter- action. Moreover, anthropologists have come to see that a vital aspect o\ f culture is its role in making life meaningful, purposeful, and understandable fo\ r people, although the meanings, purposes, and understandings people derive from t\ heir cultures differ across societies or even across sectors of the same soci\ ety (e.g., the rich vs. the poor, men vs. women, dominant vs. subordinate ethnic or\ sexual identity groups, the disabled vs. the able-bodied, doctors vs. patients)\ . Increas- ingly, in a globalizing world, where ideas, images, commercial products,\ tech- nologies, corporations, people, and diseases move rapidly across nationa\ l borders and local sites, cultures are changing. This is in turn leading to arena\ s of broadly shared behaviors and interconnectedness (e.g., global cell phone or int\ ernet use, global youth culture), sometimes referred to as the flattening of culture, as well as emergent forms of local difference that reflect the culturally specifi\ c ways global connections are mediated on the ground in different societies. Understan\ ding these sociocultural changes and the forces driving them are issues high \ on the agenda of contemporary anthropology.

Health Inequality Finally, through an examination of the issues of health inequality, such\ as the routine exposure to pesticides among farmworkers, on the one hand, and t\ o environmental degradation that causes environment-related diseases, on t\ he other, the book underlines the need for going beyond cultural or even ec\ ological models of health toward a comprehensive, biocultural health anthropology\ . Such an approach integrates biological, cultural, and social factors in build\ ing unified theoretical understandings of the origin of ill health while contributin\ g to the development of effective and equitable national health-care systems (e.g., Rylko- Bauer and Farmer 2002). In this manner, health anthropologists seek to \ be part of a collective process aimed at creating a healthier world for both hum\ anity and the biosphere and thereby prevailing over widespread patterns of hea\ lth and social injustice and environmental destruction. 10 Chapter 1 Defining Health Anthropology There is no simple definition of health anthropology because health an\ thropolo- gists are involved in so many different issues and kinds of work. Stemmi\ ng from this range, any easily crafted definition falters because it leaves ou\ t as much as it holds in. In effect, this whole book is designed to define health anth\ ropology.

Generally, however, health anthropologists are engaged in using and expanding many of anthropology’s core concepts in an effort to understand what \ sickness is; how it is understood and directly experienced and acted on by suffer\ ers, their social networks, and healers; and how health-related beliefs and practic\ es fit within and are shaped by encompassing social and cultural systems and so\ cial and environmental contexts. In this multifaceted task, health anthropologists take a page out of Shakespeare’s comedy The Merry Wives of Windsor in defining their domain of research: “Why, then the world’s mine oyster, / Wh\ ich I with sword will open.” In other words, health anthropology is concerned no\ t with a single society or with a particular health-care system but rather with h\ ealth issues throughout the whole world and even through time. Our swords, so to spea\ k, are strategies of research that are based on fieldwork and related met\ hods that are close to the experience of those being studied. Further, our armory \ includes the application of knowledge gained through research in addressing press\ ing health issues, especially among populations marginalized by existing str\ uctures of power. While recognizing the fundamental importance of biology in health and illness, health anthropologists generally go beyond seeing health as pri\ marily a biological condition by seeking to understand the social origins of dise\ ase, the cultural construction of symptoms and treatments, and the nature of inte\ ractions between biology, society, and culture. Health anthropology “seeks to consider both the cultural and biological parameters of disease” as interactin\ g biocultural processes (Joralemon 2017:11). Also, health anthropologists tend not to accept any particular health-ca\ re system, including Western biomedicine, as holding a monopoly on useful h\ ealth knowledge or effective treatment; rather, we see all health-care systems\ —from advanced nuclear medicine or laser surgery to trance-based shamanic heal\ ing or acupuncture—as cultural products, whatever their level of healing effi\ cacy and however efficacy is defined within particular healing traditions.

Culture and Biology Health anthropologists seek to understand and to help others see that he\ alth is rooted in (1) cultural conceptions, such as culturally constituted way\ s of experi- encing pain or exhibiting disease symptoms; (2) social connections, such as the type of relations that exist within the family or within society and the encompass- ing world political and economic system generally; and (3) human biolo\ gy, such as the threat of microscopic pathogens to bodily systems and the body’\ s immune responses to such threats. In pursuing these lines of inquiry, health an\ thropolo- gists are especially concerned with linking patterns of disease, confi\ gurations of Introduction to the Anthropology of Health 11 Pain and Bioculturalism Bioculturalism refers to the significant interactions that take place between biology and culture in health and illness.

Consider the issue of pain. In childbirth, a baby with a comparatively large head pushes its way through a small birth channel, a process that often produces “intense labor pains” among women giv- ing birth in the United States. While these pains are expected, they are not accepted as tolerable, and the medical administra- tion of painkillers is commonly demanded, sometimes vehemently so. In Poland, by contrast, labor pains are not only expected but also accepted, and pain- killers are not normally requested. What accounts for these differences? While pain on one level is biological, part of a bodily communication system composed of nerves that ensures urgency in limiting bodily damage (e.g., pulling one’s stray finger from the fire), health anthropologists have argued that pain expression and experience can be understood only in a cultural context. Culture teaches us how to think about, experience, and respond to the sensation of pain. Health anthropology research on the intense and chronic pain associated with temporomandibular joint dysfunction (TMD)—diseases of the joint connecting the jawbone to the skull—is instructive (Eaves et al. 2015) While not debilitating, TMD pain is aggravated by routine and otherwise enjoyable activities of daily life, including smiling, eating, laughing, and kissing. Multiple interviews with a sample of TMD sufferers in Portland, Oregon, and Tucson, Arizona, showed that they tried to minimize pain through constant vigilance to avoid flare-ups, while seeking to remain stoic in the face of pain when it occurred.

Further, participants attempted to avoid being perceived as someone who wants attention because of their pain. These goals often led to avoiding social activ- ities, hiding pain in public places, and enduring some pain to diminish being perceived as unfriendly. Rather than being biologically determined, these TMD pain management behaviors appear to reflect core values of contemporary neoliberal market-based medicine, which empha- sizes a “culture of self-help, privatization, and individualization of health” (Dutta 2016: 68). In assessing a disease, it is import- ant to consider how biology and culture interact. For example, it is likely that a devout Jew or Muslim could be made violently ill by being forced to eat pork, while consuming this meat is consid- ered very satisfying among most people in New Guinea. The same could be said of monkey brains, worms, or hamburger, depending on the cultural traditions of the people involved. Cultural beliefs and practices are very involved as well in the spread and reaction to many infectious diseases, such as sexually transmitted diseases. Disease rarely acts as an inde- pendent biological force whose health impact is everywhere the same. Rather, disease expression is shaped by cultural values, beliefs, and expectations. Cultural practices may inhibit or promote disease spread, and, conversely, disease can sig- nificantly mold culture. 12 Chapter 1 health-related beliefs and behaviors, and healing systems with cultural \ systems, social hierarchies, and biosocial relationships. Consequently, health an\ thropolo- gists have tended to look at health as a “biocultural and biosocial p\ henomenon,” based on an understanding that both physical and sociocultural environme\ nts in interaction determine the health of individuals and of whole populations\ . Central to our understanding is that while biology impacts social and cultural p\ atterns, such as the ways recent emergent infections have affected our understanding and attitudes about the world around us, the reverse is also true. Culture a\ nd social organization impact biology. To cite but one example, research has shown\ that average adult heights consistently increase with improved economic condi\ tions and decrease as economic conditions decline across time and location. Th\ is is tied to the impact of cultural and social forces on access to food and other \ resources.

In other words, “economic conditions [are] indelibly written into and\ onto the body” (Goodman 2013:365). Human biology exhibits a high degree of fl\ exibil- ity and is as much a product of culture as it is of genetics. This insig\ ht has taught anthropology that the most accurate way of thinking about humans is conc\ eiving of them as biocultural beings in which there is constant impactful interaction among our biology, our culture, and our surrounding environment. Some health anthropologists, those who call themselves critical health anthropologists (including the authors of this book), stress what they\ call a critical biocultural model, one that is especially concerned with investigating the role of social inequality in shaping health, health-related experien\ ce and behavior, and healing, issues we will explore throughout this book. What\ ever their theoretical perspective (and several alternative perspectives exi\ st within the discipline), however, health anthropologists tend to have an applied or\ ientation; they are concerned with putting their work to good use in addressing rea\ l and pressing health-related problems in diverse human communities and contex\ ts (e.g., Rylko-Bauer et al. 2006).

History of Health Anthropology The Straits Expedition Interest in health-related issues within anthropology dates to the very \ origins of the discipline as a field-oriented social science. In 1898, three Brit\ ish research- ers—W. H. R. Rivers, fellow physician C. G. Seligman, and Alfred Hadd\ on— initiated the historic Cambridge University Torres Straits (Australia)\ expedition, one of the earliest anthropological research projects. Various kinds of \ data on indigenous Australian peoples were collected during this expedition, including information on traditional healing beliefs and practices. Rivers, who so\ me see as the father of health anthropology, used data from the expedition to refu\ te the popular notion among Western physicians and other worldly observers of t\ he era that the ethnomedical practices of non-Western societies were “a \ medley of disconnected and meaningless customs” (Rivers 1927:51). Instead, he argued, ideas and practices around health and healing found in preliterate socie\ ties constitute internally coherent structures of cultural beliefs about the \ causes of disease. Now ninety years old, this perspective on healing systems around the Introduction to the Anthropology of Health 13 world has been abundantly supported by subsequent research in health ant\ hro- pology and has guided numerous examinations of the nature of the relatio\ nship of health beliefs and practices to the encompassing cultural context in \ which they are found, such as faith healing in the context of folk Christianity, as\ in the case of El Santuario de Chimayó, a Catholic healing church in New Mexico, \ shown in figure 1.1. This pattern is not limited to folk traditions but incl\ udes the dom- inant healing system, biomedicine, within modern Western society and glo\ bally.

For example, in the 1989 book The Woman in the Body: A Cultural Analysis of Reproduction, an influential text in health anthropology discussed in chapter 3, Emily Martin shows that the dominant metaphors in biomedicine for the de\ livery of babies come from the arena of industrial production. In her examinati\ on of medical textbooks, Martin found that reproduction is talked about and taught to students using analogies and concepts borrowed from factory production. \ In this biomedical cultural model of birth, (1) the doctor is portrayed as the\ manager of the laboring process, much like a factory foreman who oversees and regul\ ates the production process; (2) the uterus is portrayed as the machinery of re\ production; (3) the mother is talked about as a kind of laborer, and hence she is \ said to be “in labor” during the birthing process; and (4) the baby is the product. This way FIGURE 1.1 Crutches left behind at El Santuario de Chimayó Church in New Mexico, where pilgrims come to get “healing soil” from a hole in the church floor. Photo by Pamela Irene Erickson. 14 Chapter 1 of viewing reproduction, Martin found, is often in conflict with the v\ iews held by women who have given birth or who are about to give birth, creating t\ he potential for misunderstandings and conflicts in childbirth.

W. H. R. Rivers and Beyond In Rivers’s book on ethnomedicine, Medicine, Magic, and Religion (1927), a volume that has been called the “symbolic totem of medical anthropo\ logy” (Landy 1977:4) because it incorporates health-related issues into the \ agenda of anthropology, Rivers also maintained that non-Western ethnomedical tradi\ tions and biomedicine constitute completely separate entities. Indigenous heal\ ing, he asserted, is characterized by manipulation, using spells and other rituals, of assumed magical connections among objects and beings in the world and by\ beliefs about the actions of supernatural beings (e.g., spirits) in ca\ using and cur- ing illness. Biomedicine, by contrast, is grounded in natural laws and s\ cientific principles. Ever since, health anthropologists have grappled with understanding similarities and differences in healing systems cross-culturally. The distinctiveness of biomedicine has been intensely debated within the field. While some\ health anthropologists have accepted it as a standard by which to assess the efficacy of other healing systems, other health anthropologists have sought to show \ the following: •Biomedicine in its understandings and practices reflects its culture of origin no less than any other ethnomedicine.

•Folk healing systems around the world incorporate practices (e.g., bone setting) that are based on obser vation and practical reason as well as conceptions and protective behaviors that are believed to be derived from natural laws, such as the hot and cold properties of foods or other elements in nature, and not just on magical or religious belief.

•Many of the ideas and practices found in biomedicine are not, in fact, based solely on natural laws and scientific principles.

Pearl Katz, in her 1999 book The Scalpel’s Edge: The Culture of Surgeons (which is described in greater detail in chapter 2), portrays modern s\ urgery as an elaborate set of rituals that function to limit ambiguity, uncertainty, \ and error.

The process of “scrubbing,” for example, involves very strict beha\ viors, within precisely designated time periods, such as washing each hand in particular ways for a specified amount of time. While it is possible to significantl\ y reduce the presence of pathogens on one’s hands and arms through careful cleanin\ g, the precisely defined rules of scrubbing appear to serve also to reduce an\ xiety about not being sufficiently germ free to avoid infecting the internal organ\ s of the patient. By closely adhering to the rituals of surgery, the confidence\ doctors and nurses need to undertake a very delicate and potentially disastrous acti\ vity, such as cutting open and in some way changing a patient’s internal environ\ ment, is heightened. As a result of such studies, biomedicine is now analyzed within health anthropology as one among many ethnomedical systems around the world, Introduction to the Anthropology of Health 15 though a rather distinctive one because of its global reach, broadly rec\ ognized efficacy in handling many health problems, and ties to the internation\ al scientific community and dominant social classes worldwide. One consequence of this\ shift in perspective is that the medical anthropological perspective “\ helps us step back from medicocentrism by refusing to take [bio]medical categories and\ their various meanings as givens” (Saillant and Genest 2007:xxvii), inclu\ ding the bio- medical tendency toward biological reductionism. As a result as well, di\ versity within biomedicine is more apparent, varying in its practice and perspec\ tives across countries and within different medical specialties.

Rudolf Virchow Returning to the origin of health anthropology, Otto von Mering (1970:2\ 72) contends that the emergence of the field dates to the late 1800s when \ Rudolf Virchow, a renowned German pathologist who is often regarded as the fath\ er of social medicine because of his interest in how the distribution of he\ alth and disease mirrors the distribution of wealth and power in society, helped \ establish the first anthropological professional society in Berlin. Virchow was \ an important early influence on Franz Boas, the father of American anthropology, wh\ ile he was affiliated with the Berlin Ethnological Museum from 1883 to 1886. Virc\ how helped to lay the theoretical foundation for the approach known as criti\ cal health anthropology, which is described below.

Erwin Ackerknecht and William Caudill During the 1940s and 1950s, Erwin Ackerknecht, a German émigré, em\ erged as an important figure in the evolution of health anthropology. Using \ field accounts from anthropologists working in various societies, Ackerknecht \ sought to develop a systematic understanding of healing beliefs and practices t\ hat emphasized that (1) healing behaviors and ideas tend to reflect the \ wider cultural traditions of the society in which they develop and that (2) whatever their ability to improve the health of patients, healing systems reinforce core cultural values and structures and contribute to maintaining the status quo by controlli\ ng social conflict and deviance.

The Postwar Period After World War II, a growing number of anthropologists began to turn th\ eir attention to health-related issues, especially applied ones. Thus, the v\ ery first review of what we now call health anthropology was produced by William Caudill eight years after the end of the war and was titled “Applied Anthropo\ logy in Medicine” (Caudill 1953). Caudill’s paper marked two important d\ evelopments in the evolution of health anthropology: (1) the entry of a number of anthro- pologists after the war into international health development work and (2) the hiring of anthropologists to work in medical schools and clinical settin\ gs as teach- ers, researchers, administrators, and, in some cases, clinicians. Involvement in 16 Chapter 1 the international health field actually began during the 1930s and 1940s within the context of British colonialism—an era during which the delivery of Western health services was seen as central to a larger effort to administer and\ control indigenous peoples.

Health Anthropology and National Development Cora DuBois became the first anthropologist to hold a formal position with an international health organization when she was hired by the World Hea\ lth Organization in 1950. Within a few years, Edward Wellin at the Rockefell\ er Foundation, Benjamin Paul at the Harvard School of Public Health, and George Foster and others at the Institute for Inter-American Affairs had joined the pool of anthropologists involved in seeking to address health-related as\ pects of technological development around the world, including the negative healt\ h con- sequences of ill-planned development projects. Another set of anthropolo\ gists became involved in efforts to facilitate the delivery of biomedical care\ to people in developed nations and underdeveloped sectors of technologically advanced nations. Alexander and Dorothea Leighton, for example, became involved i\ n the Navajo-Cornell Field Health Project. This applied initiative created the social role of “health visitor,” a Navajo paramedic and health educator w\ ho acted as a “cultural broker” or community liaison between the white-dominat\ ed health- care system and the Navajo people.

The Discipline Is Born Whatever its diverse roots, as a distinct and labeled subdiscipline of a\ nthropol- ogy, health anthropology has a relatively short history that can be trac\ ed to the period after World War II (Roney 1959). Organizationally, health anthr\ opology began with the formation of the Group for Medical Anthropology in 1967, \ with Hazel Weidman, an applied anthropologist, as chair. Ultimately, this fl\ edging organization became the now quite robust Society for Medical Anthropolog\ y, a formal section of the American Anthropological Association since 1972,\ with Dorothea Leighton, a psychiatrist-anthropologist, serving as its first\ president.

As the field continued to grow and diffuse, health anthropology associ\ ations formed subsequently in other nations as well. Today, as described throug\ hout the rest of this book as well as in several others that bring together t\ he range of work done in the field (e.g., Brown 1998, Sargent and Johnson 1996\ ), health anthropology continues to grow in size and diversity of work as w\ ell as in terms of the impact of the efforts of health anthropologists on a wid\ e range of health-related issues internationally. As in any field, there have been disagree- ments and debates as well as frustration about structures that sometimes\ restrict the influence of health anthropology on health-related policy making, \ and there have been worries about how to have a bigger role in shaping public heal\ th dis- cussions to include issues of culture, social organization, and the voic\ es of socially marginalized populations. As reflected in this book, even the issue of\ what to call our field of study remains open to debate. Introduction to the Anthropology of Health 17 The Relationship of Health Anthropology to Anthropology and to Other Health-Related Disciplines Health Research and the Subfields of Anthropology Traditionally, anthropology in the United States, at least, has comprise\ d four subfields: social and cultural anthropology, biological anthropology, \ archaeol- ogy, and linguistics. In other countries, such as the United Kingdom and\ Austra- lia, the discipline has focused more narrowly on social and cultural ant\ hropology.

While some have proposed that health anthropology constitutes the fift\ h subdis- cipline of anthropology, others see it as sitting on the cusp between cu\ ltural and biological anthropology and incorporating elements of each in its unders\ tandings of health, illness, and healing. An alternative perspective places healt\ h anthro- pology on the cusp between general or theoretical anthropology and appli\ ed anthropology. In this book, as we have stressed, a primary focus is on t\ he applied side of health anthropology as a biocultural approach to addressing heal\ th issues. Health anthropology has become one of the largest topical interest areas\ beyond the four primary subfields of the discipline. One of the curren\ t debates within health anthropology is the degree to which it has had an impact i\ n shaping the ideas and orientation of the wider field of anthropology, includin\ g to what degree health anthropology has developed its own theories and to what de\ gree it has merely borrowed and applied those found elsewhere in the discipline.\ Health Anthropology and Paleopathology Health anthropology has developed an important interface with archaeology.

In that archaeology in the United States is often defined as part of s\ ociocultural anthropology or at least as part of one of the four subfields of anthropology, the bridging nature of health anthropology is particularly apparent in the field called “paleopathology,” which is the study of diseases in the pas\ t and, partic- ularly, in prehistoric times. This research is accomplished through the \ study of human fossil remains recovered through archaeological excavations. Buiks\ tra and Cook (1980) delineate four stages in the development of paleopatho\ logy: (1) the descriptive period during the nineteenth century, focusing on \ bone abnormalities; (2) the analytical period during the early twentieth ce\ ntury, when an attempt was made to interpret bone abnormalities; (3) the period be\ tween 1930 and 1970, when the field became more specialized, drawing on fields such as radiology, histology, and serology; and (4) the current phase \ beginning around 1970, when the field became considerably more interdisciplinary\ and incorporated genetic studies, including examination of microbial DNA in bone and soft tissue in order to diagnose disease in past humans. As Roberts and Manchester (1995:9) point out, one of the important lim\ ita- tions of paleoanthropology is that the populations being studied are lon\ g dead, and consequently the number of cases being studied from any population are limited, a mere “sample of a sample of a sample.” As a result, it is difficult to generalize to the whole population from which the cases are drawn. 18 Chapter 1 Applied Anthropology in Action Health anthropology straddles the line between theoretical and applied anthro- pology. Applied anthropology is the appli- cation of anthropological theories, con- cepts, and methods to solving problems in the world. Applied anthropologists work in many different areas, from A for aging, such as solving problems in the isolation aging people often feel in Western soci- ety, to Z for zoos, as seen in work done to determine how to use zoos to edu- cate visitors about pressing environmen- tal issues. While it is sometimes asserted that applied anthropology grew out of theoretical anthropology, the reverse is in fact the case. In the United States, for example, some of the individuals who first found employment as anthropolo- gists worked for the Bureau of American Ethnology (BAE). The BAE was set up in 1879 as a policy research arm of the federal government to provide research needed to inform congressional decisions about the American Indian population.

The bureau’s first director, W. J. McGee, proposed that the organization focus on what he called “applied ethnology,” which led to a series of descriptive reports that were prepared for policy makers. Despite this fact, there have been strong tensions at times between applied and theoretical anthropology. Some theoretical anthro- pologists identify the discipline’s mission as understanding diverse pathways in human social life. They assert that to use anthropology to formulate planned social change violates two basic disciplinary principles: cultural relativism, which pro- scribes judging any given society by the values of any other, and avoidance of research bias, which includes, among other concerns, the scientific standard of minimizing opportunities for data contami- nation because of the value commitments of the researcher. Both of these principles suggest that intervention is, by definition, not anthropology. Applied anthropologists counter that science does not exist in a social vacuum and that its fundamental purpose is to apply its findings to solv- ing human problems and improving the quality of human life. Because we live in a world of cultural contact and resulting social change that often leads to pressing problems and extensive human suffer - ing, applied anthropologists feel obliged to apply their skills and understandings to solve real-world challenges. In recent years, these divisions have begun to break down, and older animosities about what is the proper role of anthropologists in society have begun to fade into history. Many nurses have found anthropology and specifically health anthropology to be of great utility in their work. Consequently, numerous undergraduate nursing pro- grams require their students to take a course in cultural anthropology, and many nursing schools now teach courses in health anthropology and related subjects.

Indeed, many of the people teaching these courses are nurses who have obtained graduate degrees in health anthropology.

Some anthropologists have argued that, in contrast to biomedical physicians, who tend to be “disease oriented,” nurses are inclined to be more “person oriented.” With this orientation, developing a health anthropology perspective appears as a useful and practical one for many nurses. A specific example of one type of work that applied health anthropologists Introduction to the Anthropology of Health 19 Despite this shortcoming, paleopathology has much to teach us about diseases and related health problems of antiquity, including congenital \ defects, traumatic injuries, infectious diseases, metabolic and nutritional disorders, degenerative diseases, circulatory problems, caries, and even cancer. Fo\ r exam- ple, bone spurs in the knees, toes, and spines of ancient Mesoamerican w\ omen strongly suggest that they spent long hours grinding maize to make flo\ ur. Paleopathology can also contribute to the solving of medical mysteries. \ A case in point is the cause of death of Pharaoh Tutankhamun, more popul\ arly known as King Tut, a relatively minor ruler historically but today the b\ est-known member of ancient Egypt’s dynastic line. On November 4, 1922, archaeo\ logists discovered and began excavating King Tut’s thirty-three-hundred-year-\ old sub- terranean royal burial tomb in Valley of the Kings, the royal necropolis\ of Egypt’s eighteenth through twentieth dynasties, located on the west bank of the Nile River opposite the modern city of Luxor. The richness of the funerary ar\ tifacts in the tomb, and the discovery of the pharaoh’s mummy, led to extensi\ ve press coverage and the rapid rise of King Tut in the popular imagination world\ wide.

A subsequent autopsy of the Tutankhamun mummy concluded that the pharaoh\ had died around the age of nineteen years. Speculation soon developed ab\ out the cause of death of the young ruler. Initial conjecture focused on the king’s skull because of a small dense spot, suggesting the possibility of brain traum\ a inflicted by a murderous blow to the back of the head. According to Bob Brier, aut\ hor of the popular book The Murder of Tutankhamen (1998), in light of the “violent, unstable times Tutankhamun ruled in, and [based on] forensic evidence \ . . . mur- der and intrigue emerged as the best explanation” (xix) of the phar\ aoh’s untimely do is seen in the efforts of Dan Small (2016) at Insite, a medically defensi- ble but culturally controversial program located in Vancouver in western Canada.

Insite is a legal, medically supervised facility for the injection of illicit drugs that is designed to reduce the potential harm (e.g., drug overdose) associated with drug use. Small’s work began with helping to identify cultural barriers to implementing this controversial health- care program. Once barriers were deter - mined, a cultural initiative was developed to shift dominant social narratives about addiction that often create barriers to programs designed to address the health needs of a socially denigrated population.

Clients of Insite are able to choose their injection equipment from on-hand sterile supplies and report which drug they are injecting. This information assists with implementing individualized emergency intervention if required. Drugs are not provided at the facility; users must bring their own. Participants are assigned to one of twelve injection booths, each of which contains a stainless-steel counter - top and mirror to facilitate the user having a clear view of their chosen point of injec- tion. There is also a nursing station for medical support staff, who provide crisis intervention, referrals to treatment, addic- tion counseling, detox, and supported housing referral. Rather than just study health risk among injection drug users, Small’s work, as an advocate of harm reduction, focuses on lowering risk in a nonjudgmental, rapport-building manner. 20 Chapter 1 death. Additionally, based on several peculiar features of statues, pain\ tings, and other ancient depictions of King Tut and members of his family (e.g., s\ uggesting androgynous characteristics among males as well as notably elongated hea\ ds and fingers), numerous speculative reports have been published about vari\ ous diseases allegedly suffered by King Tut. Among these are Marfan syndrome, a genet\ ic disorder that leads to above-average height, long slender limbs, and lon\ g fingers and toes; Wilson-Turner X-linked mental retardation syndrome, a congenital disease characterized by mental disabilities, childhood obesity, and enl\ arged male breasts; and Fröhlich syndrome, a disease caused by tumors of the hyp\ othalamus that produces mental retardation and retarded sexual development. In par\ t to test these various hypotheses, Zahi Hawass, an archaeologist and Egypt’s s\ ecretary general of the Supreme Council of Antiquities, led an international team that carried out a set of now widely publicized anthropological, paleopatholo\ gical, radiological, and genetic analyses of a group of mummies as part of the \ King Tutankhamun Family Project. While discounting various earlier hypotheses about King Tut’s death, this study concluded that a likely cause of d\ eath was the occurrence of multiple health problems including malaria (based on fi\ ndings of ancient malaria DNA in King Tut’s mummy), juvenile aseptic bone necr\ osis or Köhler disease II (involving loss of blood to the king’s left foot, causing bone death and collapse), and a fracture of his left femur that was unhealed\ at the time of death. King Tut’s death, in other words, was a consequence neither\ of intrigue and ancient rivalry nor of a rare and disforming genetic disorder, but r\ ather was caused by the adverse interaction of several diseases and trauma-induced\ infec- tion (Hawass et  al. 2010). Most important, this study suggested the possibility that malaria, alone and in interaction with other diseases and condition\ s, was an important factor in the health of all sectors of ancient Egyptian societ\ y.

Health Anthropology and Epidemiology The AIDS Connection Beyond its ties to subfields within anthropology, health anthropology \ also has an important connection with epidemiology, a discipline concerned wi\ th the patterns and spread of disease, including containing outbreaks of di\ sease.

At the U.S. Centers for Disease Control and Prevention (CDC), a branch\ of the national Public Health Service, scientists monitor the appearance an\ d spread of disease all over the country and beyond. In the AIDS epidemic, for example, CDC researchers attempted to understand what was causing the disease, how it was spread, and how it could be stopped. There has been a long but in some ways not always deep collaboration between epidemiologists and health anthropolo- gists. Well over three hundred health anthropologists, for example, have\ worked on some aspect of the global AIDS epidemic, often in close partnership w\ ith epidemiologists and other researchers and interventionists (Bolton and Orozco 1994), although far fewer work on the epidemic today. In this work, as \ Patricia Whelehan notes in her 2009 book The Anthropology of AIDS: A Global Perspec- tive, health anthropologists have addressed various bio-sociocultural factor\ s, ethical issues, cultural factors and social reactions, gender roles and \ relations, Introduction to the Anthropology of Health 21 sociopolitical and socioeconomic influences, and transnational and int\ ergroup differences in the nature of the impact and range of responses that have\ developed to the pandemic. Health anthropologists have played various roles in the global AIDS pandemic. To cite one example, they have worked closely with outreach workers who locate and recruit hard-to-reach at-risk individuals, such a\ s injection drug users, for interviews by the anthropologists on patterns of HIV ris\ k and/ or for participation in prevention interventions. Research of this sort \ has led to discoveries by health anthropologists and their colleagues of a range of\ behaviors beyond direct syringe sharing that can spread the virus that causes AIDS\ as well as sexual risk associated with injected and noninjected drug use (such \ as the use of crack cocaine). In addition, health anthropologists were involved in\ identifying social and behavior contexts in which risky behavior is most frequent, a\ ssessing the role of social networks in the spread of HIV infection and the importance of exposure to violence in risk behavior, and have played key roles in p\ revention research on syringe exchange. Broader social and political issues have also been addressed by anthropo\ lo- gists in the AIDS pandemic. In her work in South Africa, for example, Ida Susser (2009) focused on women’s avenues of hope, sources of resilience, and mount- ing community activism in response to the toll of AIDS. Central to Susse\ r’s objective was the development of a detailed account of women’s on-the\ -ground responses to the entwined effects of disease, gender discrimination, and\ the world economic system through which wealthy countries promote deprivation, soc\ ial suffering, and the spread of disease in poorer nations. Notably, Melissa Parker (2003:179), who studied unsafe sex among gay-identified men in the back rooms of pubs, clubs, and saunas in Lon\ don, has argued that anthropologists should “draw upon their ethnographic expe\ rtise and help to design interventions which target people and places with the\ explicit intention of promoting social change and saving lives.” Health anthropologists who continue to work in the HIV/AIDS epidemic have a strong focus on treatment and its impact on populations.

Cultural Epidemiology In his book Epidemiology and Culture, James Trostle (2005), an anthropologist long concerned with building collaboration between epidemiology and anthro- pology, argued for the creation of a “cultural epidemiology” that \ would integrate the anthropological concept of culture into the set of explanatory varia\ bles used by epidemiologists to explain disease. Cultural beliefs and practices ab\ out con- dom use, for example, contributed to the spread of HIV infection. Becaus\ e many people link condom use to casual intercourse with people other than thei\ r main partner, at times it has been difficult to convince them to use condom\ s in their primary relationships. Another example of how culture impacted HIV preve\ ntion was provided by Alexander Rödlach (2006) in his study of AIDS-relat\ ed beliefs in Zimbabwe in sub-Saharan Africa. Rödlach found that many people in Zim\ babwe wondered if the disease was spread either by sorcery or because of a con\ spiracy, such as a plot by the U.S. government to punish people of color. Importa\ ntly, he argued that studying such beliefs, which are widespread in the world,\ is not an 22 Chapter 1 attempt to contribute to the construction of an exotic other (i.e., viewing people who are culturally different as bizarre or less intelligent). Rather, h\ e emphasized that developing a better understanding of cultural beliefs about the nat\ ure and spread of AIDS “yields theoretical insights into how people explain a\ nd react to health problems, [which] in turn benefits health programs” (2006:1\ 3). Sorcery and conspiracy beliefs, he notes, are prevalent in social groups that ha\ ve endured suffering, through poverty, discrimination, and disempowerment, at the h\ ands of outsiders. Such beliefs, in other words, are culturally constituted idioms of dis- tress that express the harmful experience of feeling helpless and unable to c\ ontrol much about one’s life (and hence suspecting a nefarious outside agen\ t as the source of one’s painful lived experiences). A similar pattern has be\ en described in accounting for the conspiracy beliefs that emerged during the 2014–20\ 16 Ebola epidemic (Ayegbusi et al. 2016, Ngade et al. 2017). Health anthropologists use the term idioms of distress to describe the culturally specific and symbolically rich frameworks of understanding through which people both experience and articu- late social discontent and suffering. In addition, they have come to rec\ ognize that even standard biomedical terms such as diabetes can come to be used popu\ larly as idioms of distress when they refer to health conditions that reflect health and social disparities and express the lived experience of social suffering.\ Health Transitions Within epidemiology, the term health transition is used to label broad changes that have occurred within particular historic phases in the health profi\ le of populations and the primary causes of mortality. The first health tran\ sition in human history began about ten thousand years ago when the development of\ agricultural modes of food production and more sedentary communities led to a marked increase in acute infectious diseases (often involving the adaptation of the disease-causing pathogens of domesticated animals such as cattle to huma\ n hosts and resulting in human epidemics). A second health transition occurred \ between the late eighteenth and early twentieth centuries with the rise of indus\ trial econ- omies. This economic and social transformation involved the restructuring of environments, industrial pollution of the air, water, and land, and chan\ ges in life conditions. These sweeping changes contributed to the growing impor\ tance of chronic diseases such as heart disease, stroke, cancer, and diabetes \ and what are termed behavior problems, such as substance abuse. Ultimately, especially as a result of public health measures supported eventually by biomedical in\ terven- tions, a drop also occurred in many developed nations in rates of lethal\ infectious diseases as well. However, one effect of the second health transition is that poorer countries now suffer from what has been called the “triple burden”\ of acute disease, such as diarrheal disease; chronic disease, such as cancer; and\ behavioral pathology, such as the global spread of illicit drug injection. At the s\ ame time, health-care systems have been changing. One force pushing such changes h\ as been the imposition of what are called neoliberal reforms by international lender institutions (i.e., banks that loan money for development to poorer cou\ ntries), such as the World Bank. In poorer nations, such as Mongolia, as health a\ nthro- pologist Craig Janes (Janes and Chuluundorj 2004) found during his res\ earch Introduction to the Anthropology of Health 23 there, lender-endorsed steep cuts in government investment in the health\ sector and the transformation of health services from a government-provided ben\ efit to a purchasable commodity resulted in a significant drop in the quality \ and quan- tity of health services available in rural areas while restricting acces\ s to services that were still in operation. Janes discovered that women in particular \ were vul- nerable to these changes, leading to increasing rates of both poor repro\ ductive health and maternal mortality. Similar negative health effects of what has been called structural adjustment (i.e., changes in government policies and structures demanded by international development loan providers such as the World B\ ank and International Monetary Fund) have been described by health anthropo\ lo- gists working in various locations around the world. As Mark Nichter (2008) indicates in his book Global Health: Why Cultural Perceptions, Social Represen- tations, and Biopolitics Matter, structural adjustment has led to a proliferation of service-providing nongovernment organizations (NGOs) in underdevelo\ ped nations. One result is that in places such as Haiti there are multiple, uncoordi- nated, and competing health programs governed by the dictates of foreign\ fund- ing institutions. This change has contributed “to the undoing of gove\ rnment services” (Nichter 2008:139) and the weakening of governments in de\ veloping nations, pushing them, as has occurred in places such as Haiti, Peru, El\ Salvador, and several countries in southern Africa, beyond the ability to meet the\ basic public health needs of their citizens (M. Singer 2010a, Smith-Nonini 20\ 10).

A study that reviewed a decade of the effects of structural adjustment p\ olicies in eight Latin American countries, for example, found that, in an effort by\ lender banks to make interest from the development loans they had made, health \ and social expenditures designed to meet human needs were cut drastically, l\ eading to ever-widening disparities between the health and well-being of the ri\ ch and that of the poor (Petras and Vieux 1992). Many of the failures of neoliberal “development,” in terms of human suffering and the promotion of po\ verty, in what amounts to a form of economic neocolonialism, are now acknowledged \ by some leaders of the World Bank. In the last decades of the twentieth century, a third health transition \ began, and it continues into the twenty-first century. This transition involves the rapid appearance and global spread of new infectious diseases such as HIV/AIDS, SARS, Ebola, Zika, and avian influenza and the development of new levels of virulence and drug resistance in older infectious diseases such as tuberculosis. In the third health transition “poverty combines with urbanization and the dissolution of\ traditional family structures to intensify [health] challenges” from infectious agents, processes of globalization (e.g., rapid travel and the global shipment of commodities) enable the brisk movement of infectious diseases around the world, and microbia\ l adap- tation to medicines weakens the effectiveness of drugs like antibiotics \ to control infectious diseases (Barrett 2010). At the same time, adverse synergis\ tic interaction among diseases (infectious, chronic, behavioral) has promoted the appearance and adverse health impact of disease “syndemics” that further increase\ the total health burden of affected populations (Bulled and Singer 2010, M. Singer 2010b, M.

Singer et  al. 2017). These factors are significantly shaping contemporary globa\ l health and appear likely to do so well into the future. 24 Chapter 1 Illness and Help-Seeking Behavior One of the important issues on which health anthropologists have focused\ is how local sociocultural factors come into play in “monitoring the body, recog- nizing and interpreting symptoms, and taking remedial action . . . to rectify the perceived abnormality” as well as “adherence to therapeutic advice\ , changes in treatment regimens [e.g., switching healers], and evaluation [and reevaluation over time] of therapeutic efficacy and outcome” (Christakis et \ al. 1994:277).

In short, health anthropologists are interested in the ways that culture\ helps to shape the “illness behavior patterns,” including help-seeking acti\ ons, found in a society. Of note, illness behavior is mediated by a sufferer’s subj\ ective inter- pretations of the meaning of experienced symptoms. However, these interpre- tations are not solely idiosyncratic but rather are influenced by wide\ r cultural understandings of illness and the comments and actions of the sufferer’\ s social network. For example, in “several areas of Africa where malaria is en\ demic, sei- zures [which in biomedicine are recognized as symptoms of malaria infect\ ion] are viewed as a ‘folk illness’ largely unrelated to malaria and are of\ ten attributed to supernatural causes” (Nichter 2008:74). Illness behavior is impacte\ d by various factors, including gender (thus men and women often “get sick” di\ fferently) and socioeconomic status. Also, illness behavior in a society is not static;\ as a society changes, illness behaviors change as well, including patterns of use of health services. The global distribution of pharmaceutical drugs, for example, \ has con- tributed to the use of these commercial laboratory remedies in ways that go far beyond their intended purposes and patterns of use, such as crushing ant\ ibiotic capsules and applying them to wounds or the emergence of local healers w\ ho administer individual antibiotic injections. Documenting and assessing e\ mergent patterns of illness behavior and their causes is a role that health anth\ ropologists are playing in the realm of epidemiology. More broadly, health anthropol\ ogists seek to move beyond the examination of individual suffering to social su\ ffering.

Health Anthropology and Public Health Closely related to epidemiology is the discipline of public health, a fi\ eld that is concerned with assessing and improving the quality of health of the g\ eneral populations as well as that of especially vulnerable and at-risk subgrou\ ps therein.

Health anthropologists contributed to public health by ethnographically \ exam- ining disease-promoting behaviors in social context. As social scientists who attempt to “elucidate how and why people do what they do,” health \ anthropolo- gists have been able to contribute to disease prevention and control (B\ rown et al.

1996:198). Failure to understand the factors that shape the behavioral \ decisions people make, the frames of understanding they bring into play, and the i\ nfluence of social relationships on their actions is a contributor to the disappo\ intments of public health interventions. Another role for health anthropologists inv\ olves the issue of public trust in public health messages. While public health wor\ kers are motivated by a commitment to improving public well-being, the population\ s they seek to assist may not share their enthusiasm or trust their intentions.\ Resistance to public health measures, for example, has been described for populatio\ ns at risk Introduction to the Anthropology of Health 25 for polio vaccination and Ebola infection. In the case of Ebola, people \ in some locales even came to question whether public health workers were bringin\ g the potentially fatal disease rather than trying to curtail it (Cohn and Ku\ talek 2016).

This pattern underlines the importance of ethnographic research on the d\ rivers of fear and public health distrust in the development of grounded unders\ tandings of public responses to and following epidemic outbreaks. Health anthropo\ logy research on the drivers of public distrust informs efforts to improve pu\ blic health communication, the nature of public health messages, the public presenta\ tion of public health interventions, and the role of community involvement in\ the context of infectious disease epidemics (Abramowitz 2014). A number of methodological and conceptual developments in public health \ in recent years have created new opportunities for health anthropology t\ o play a part in public health discussions and interventions. Among these new dev\ elop- ments are (1) the growing public health and medical concern with healt\ h inequi- ties, (2) the increasingly recognized need to enhance the cultural com\ petence of health-care providers, (3) the emergence and growing influence of th\ e communi- ty-based participatory research model, (4) the diffusion of and increa\ sing funder emphasis on evidence-based interventions in public health, (5) the mou\ nting demand for translational research that allows the findings and knowled\ ge pro- duced by health-related studies to shape health intervention efforts, and (6) the spiraling interest in what have come to be called complementary and alte\ rnative medicines. At the same time, a research method developed within anthropo\ l- ogy—rapid ethnographic assessment—has spread into public health, c\ reating additional opportunities for health anthropology to have an impact on he\ alth issues. Each of these increasingly important arenas of public concern in\ which health anthropology directly or indirectly has played a role is describe\ d next.

Health Inequity or Disparity Health inequity or disparity refers to the significant differences in the health profiles (i.e., the distribution of diseases and wellness) across hu\ man populations, social strata such as social classes, or other segments of the populatio\ n, such as rural areas compared to urban settings. Additionally, health disparities\ research- ers are concerned with why disparities in health exist. In the United St\ ates, for example, as Grace Budrys (2003:39), observes in Unequal Health: How Inequal- ity Contributes to Health and Illness, from a health standpoint “being at the top of the [social class] heap is a lot better than being on the bottom. \ .  .  . There has been an explosion of research indicating that social class is a powe\ rful, and arguably the most powerful, predictor of health.” Critical health anthropolo- gists, for example, have examined the roles that economic structures (e\ .g., wage constraints) and health insurance companies (e.g., ability to pay for \ coverage vs.

actual medical need) play in limiting people’s ability to make healt\ hy choices in their lives (Fletcher 2017). The nature and importance of health inequities will be examined in great\ er detail in chapter 4. Suffice it to note here that it is an important h\ ealth arena in which a number of health anthropologists have become quite active, su\ ch as Sabina Rashid, who works among the poor of Dhaka, Bangladesh (figure \ 1.2). 26 Chapter 1 Community-Based Participatory Research There are various approaches to research on health issues in specific \ populations and communities. In the “unilateral research model,” researchers b\ ased at univer- sities or research centers design a research project based on their unde\ rstanding of the key issues and questions. The research agenda in this approach is\ almost completely if not completely determined by the researchers in terms of t\ heir conceptions and interests. After a project is largely designed, the rese\ archers may contact and subcontract with a community organization to recruit par\ tici- pants from the community who will be interviewed in the planned study. O\ ften strapped for funding, community organizations accept such subcontracts even though they may at the same time resent not having much voice in planning the study, including a say in what from the community’s perspective a\ re the key health issues in need of research. Another approach to research is c\ alled the “collaborative model.” In this approach, while researchers initially conceptualize a study, they then contact one or more organizations based in the commun\ ity of concern and invite them to participate in fleshing out the details \ of the study.

While the community organization(s) participates at some level in the study, the bulk of project direction, decision making, and funding is still centere\ d in the university or research institute. Both unilateral and collaborative rese\ arch projects are very common and can be found on most university campuses, often fund\ ed by federal research grants or private health foundations. As contrasted with both of these approaches to research, community-based\ participatory research (CBPR) is based on a full partnership between r\ esearchers and community representatives and organizations, from project conception\ to FIGURE 1.2 Children from poor families in an urban slum in Dhaka, Bangladesh. Photo by Sabina Faiz Rashid. Introduction to the Anthropology of Health 27 completion, including publication of findings. Community-based partici\ patory research grew out of recognition that traditional population-based biome\ dical research methods lack authentic community involvement and often result in community alienation from research and researchers. In some cases, researchers have come to be defined as exploiters of communities rather than as th\ eir natural allies. Consequently, in CBPR-guided projects, the community plays a key\ role in setting the research agenda. In this, communities are guided by their\ pressing need for specific health-related knowledge, which can be used in addre\ ssing com- munity health problems and in making ongoing decisions about the directi\ on of the research. As the concept of CBPR has developed and its value recogni\ zed, various efforts have been made to establish guidelines for successful an\ d mutually satisfying participatory research projects. Health anthropologists have contributed to the development of this alter\ na- tive orientation to research. For example, the Institute for Community R\ esearch in Hartford, Connecticut, a community-based organization that has been led by anthropologists since its founding, established the Youth Action Rese\ arch Institute to promote the use of a participatory action research model am\ ong youth. Central to the institute’s work have been projects that involve minority youth in ethnographic research on issues of concern to the youth (e.g., AIDS and substance abuse), including the primary health and social problems face\ d by their communities. Anthropologists train youth in ethnographic methods and help them identify problems for action research. The goals of this proje\ ct were personal growth among the youth participants, the development of positiv\ e peer norms, and the assessment of community health needs.

Diffused Evidence-Based Intervention There has been a strong effort in recent years to accelerate the movemen\ t of scientifically proven (i.e., evidence-based) intervention models, su\ ch as train- ing programs to assist people in avoiding communicable diseases. Rather \ than funding organizations to implement intervention models that have not been evaluated, funder institutions, such as the CDC, began emphasizing the u\ se of models that have proven to be effective. The CDC’s Diffusing Effectiv\ e Behav- ioral Interventions project, for example, has helped implement eighteen \ different research-based infectious disease prevention models through community-ba\ sed organizations, health departments, and other prevention providers across\ the United States. These were designed for specific populations, such as i\ njection drug users, sexual and romantic partners of injection drug users, men wh\ o have sex with men, heterosexuals at high risk, people living with infect\ ion, and homeless and runaway adolescents. To prepare community organizations to suc- cessfully implement these intervention models in their respective commun\ ities, the researchers or those they have trained are called in to provide guid\ ance and technical assistance to the frontline people who would use the models in\ day-to- day prevention work.

Translational Research Translational research is a specialized type of research carried out wit\ h the inten- tion of improving the flow of knowledge from research into action in p\ ublic 28 Chapter 1 health or some other arena of social intervention. Health practitioners \ and policy advocates, for example, have complained that the findings of behaviora\ l research are slow in finding their way to public prevention efforts. For exampl\ e, anthro- pologists and others who conduct ethnographic research with injection dr\ ug users have observed that they engage in a number of behaviors during the\ con- sumption of drugs that might lead to infection. One of these behaviors i\ nvolves several drug users pooling their money to purchase a packet of an illici\ t drug, such as heroin or cocaine, and then mixing it with water, using one of t\ he partic- ipant’s syringes and the unit gauge on its barrel to measure the righ\ t amount of water to allow an equal distribution of the dissolved drug. If the syrin\ ge that is used for this purpose contains an infectious agent, then the virus may b\ e flushed into the container (such as a bottle cap) that is being used for drug \ mixing and drawn up by all the individuals who are sharing the drugs from that container.

In this way, all these individuals may be exposed to infection. An exami\ nation of the messages given by prevention programs to drug injectors to protect t\ hem- selves, however, often urges them only not to “share needles.” Bec\ ause individ- uals who share drugs may never share a needle, they may falsely believe \ that they are protected from infection when in fact other behaviors in the drug pr\ eparation and use process are causing disease transmission. As a result of examples like this, those involved in translation researc\ h have urged social scientists not only to publish their findings in professi\ onal journals, most of which are not widely read outside of academic and research setti\ ngs, but also to take specific steps to ensure that their research is readi\ ly accessible to, relevant for, and understood by those who work in prevention program\ s or who make health policy decisions. A fundamental issue facing the health inter- vention is “how to translate the research findings for more widespr\ ead practice” (Sloboda 1998:203). The need for readily accessible and usable knowled\ ge is particularly great in intervention efforts targeted to populations that \ are harder to reach and harder to retain in public health programs, a task that has\ been taken on by a number of health anthropologists. At the same time, interv\ entions models proven effective at the local level, if they are to have a signifi\ cant impact on disease, must be scaled up beyond the pilot level. For example, with \ regard to AIDS prevention programs in Africa, Binswanger (2000:2173) argues, “\ In most of Africa, there are examples of excellent HIV/AIDS prevention, mitigati\ on, and care projects. These projects reach only a small fraction of the populat\ ion how- ever. Like expensive boutiques, they are only available to a lucky few.”\ This too is a type of work that is well suited to the skills and interests of hea\ lth anthropol- ogists because “translating recent research advances into communities\ at risk . . .

requires thoughtful adaptation to meet the needs of the community effect\ ively with emphasis on social, economic, and cultural heterogeneities” (McGarvey 2009:242). It also requires creativity and a keen awareness of the cultural life and social context of target populations (figure 1.3).

Complementary and Alternative Medicine There has been a fairly dramatic shift in recent years in the way policy\ makers, health-care providers, and the general public view healing systems beyon\ d the dominant biomedical approach. One indication of this change is the remak\ ing Introduction to the Anthropology of Health 29 of the American pharmacy. Today the shelves of the average major chain p\ har- macy in the United States and Australia (although not everywhere in the\ world; see figure 1.4) are filled with over-the-counter alternative medici\ nes, such as St.

John’s wort, echinacea, and black cohosh, that in the past could have\ been found only in specialty health food stores or alternative markets. Moreover, i\ n 1992 the U.S. Congress established the Office of Alternative Medicine, which in\ 1999 became the National Center for Complementary and Alternative Medicine, one of t\ he twenty-seven research institutes and centers that make up the National I\ nstitutes of Health. The mission of the center is to promote scientific exploration\ of promising nonbiomedical healing practices and to disseminate research-based inform\ ation on these practices to the public and health professionals. While some have \ argued that the new interest in complementary and alternative healing systems is dri\ ven, at least in part, by a desire to subordinate them to the dominant biomedical syst\ em (Baer 2004), there clearly has been a significant change in the way they ar\ e viewed and their place in Western societies if not globally. We will return to the \ issue of comple- mentary and alternative medicine later in the book as we explore alterna\ tive health approaches. Here, suffice it to say that the rise in interest in compl\ ementary and alternative medicine rests on and grew out of a long history of anthropological study of nonbiomedical healers and their approaches to the treatment of illnes\ s.

Rapid Ethnographic Assessment The rapid ethnographic assessment approach to research, which has now be\ en adopted by health promotion institutions around the globe, was first f\ ully FIGURE 1.3 AIDS educators in Havana, Cuba. Photo by G. Derrick Hodge. 30 Chapter 1 described in the late 1980s and early 1990s by anthropologists Susan Scr\ imshaw and Elena Hurtado. Rapid ethnographic assessment is designed to bridge t\ he gap between science and public health practice and policy by allowing th\ e swift movement from community-based research on health or other pressing socia\ l issues to interventions based on research findings. While ethnographic\ research traditionally was both a labor- and time-intensive approach, Scrimshaw sought a methodology that would take advantage of close-up ethnographic insight in a community of concern without requiring the customary year or more of soc\ ial immersion and extensive documentation of behaviors and events characteri\ stic of traditional anthropological fieldwork. Rapid approaches do this by \ prepar- ing researchers to build on existing knowledge of a target community and\ to implement several strategies for the rapid development of rapport, such \ as the use of local staff to collect information in their own communities and c\ ollabo- ration with local community organizations, in the assembly of highly foc\ used data on very specific issues and problems. For example, in Project RAR\ E (Rapid Assessment, Response, and Evaluation), anthropologists and other resear\ chers used focus groups, quick-intercept interviewing, concentrated field observa- tion, and social mapping to identify and describe gaps in the existing a\ rray of AIDS prevention programs and services in several dozen cities across the United States. In the Hartford RARE project, for example, the research team, which FIGURE 1.4 Modern pharmacy in Cuba lacks the many over-the-counter commercial “folk medicines” now found in U.S. pharmacies. Photo by G. Derrick Hodge. Introduction to the Anthropology of Health 31 consisted of people from the local community led by several community-ba\ sed health anthropologists, found that late-night (midnight to 4:00 a.m.) \ sexual and drug use behavior was not being addressed by existing AIDS prevention ef\ forts, resulting in a continued spread of HIV in the local population. As a res\ ult of the project, the city health department began to require late-night preventi\ on efforts by some of the organizations that it funded to prevent the spread of AIDS in the city. The value of rapid research methods has been recognized in oth\ er fields as well, leading to the development of other types of accelerated assess\ ment and evaluation models, such as rural rapid appraisal, rapid epidemiology, ra\ pid disas- ter assessment, and rapid assessment of biomedical conditions. All these\ present emergent arenas of employment for health anthropologists.

Health Anthropology and Bioethics Bioethics emerged as a new academic field during the 1970s and has qui\ ckly become an important force in science and medicine and, through the setti\ ng of health-related social policies and the rise of institutional review boar\ ds (IRBs), in health anthropology as well. The term bioethics can be defined as a branch of the field of ethics that is concerned with the establishment and application of standards and principles by which human actions within the arenas of hea\ lth care, health-related decision making, and health research can be judged morall\ y right or wrong. Many hospitals, for example, employ experts on bioethics to pr\ ovide consultation on the treatment of terminally ill patients and to inform decision making regarding issues such as organ transplant, abortion, euthanasia, \ in vitro fertilization, and the allocation of scarce clinical resources. As Evere\ tt (2006:46– 47) points out, while it is likely that, because of the kinds of research they do, health anthropologists would have something important to offer, “they\ have found it especially difficult to find a place within bioethics debat\ es” that tend to be dominated by the fields of philosophy, law, and biomedicine. Health\ anthro- pologists, in fact, have sometimes been critical of bioethics because of\ a lack of sensitivity to cultural differences. Rayna Rapp (2000a:44), a health a\ nthropolo- gist who does ethnographic research on genetic counseling, for example, argues that bioethics is “self-confidently unaware of its own sociocultura\ l context” and fails to consider whether the standards it develops reflect the values\ of non-West- ern populations. Thus, bioethics has emphasized the importance of respec\ ting individual autonomy, free will, and self-determination and thus has oppo\ sed forc- ing patients or research participants to do things against their will or\ without their full consent. The problem, health anthropologists point out, is that the\ values emphasized in bioethics reflect the Western celebration of individuali\ sm, a moral stance that is not shared by cultural systems that emphasize collectivis\ t models or rigid social hierarchies. The narrow application of Western ethical s\ tandards without sensitivity to alternative norms may be construed as ethical imp\ erialism. Moreover, bioethics has been used in the effort to set standards for eth\ ical research in light of a past history of gross violations of the rights of\ human sub- jects in research. All universities and research centers now have IRBs t\ hat apply standards established for medical research to all forms of research invo\ lving 32 Chapter 1 human subjects. According to these standards, all research that has pote\ ntial risks for human participants, including research by health anthropologists, mu\ st be reviewed and approved by an IRB. A number of anthropologists have questi\ oned the appropriateness of IRB review of ethnographic research on the grounds that it commonly involves the misapplication of standards that were establish\ ed for biomedical and experimental research where life and death risks are not uncom- mon (Marshall and Koenig 1996). Further, there has been some concern t\ hat IRBs may require anthropological researchers to engage in behaviors that\ create rather than avoid ethical dilemmas, such as mandating that research part\ icipants sign informed consent forms that result in participants’ names being \ part of a project’s records. In the study of illegal behaviors, such as illicit\ drug use or prostitution, this may contradict the researcher’s commitment to prot\ ect the confidentiality of study participants. Health anthropologists recogniz\ e that the kind of research they conduct commonly encounters perplexing ethical dil\ emmas and recognize the need for ethical principles to guide their research ac\ tivities.

Whether bioethics is the appropriate source for such principles is an is\ sue of debate. Whatever the challenges, as discussed further in chapter 8, ther\ e is little doubt that health anthropology will continue to engage and develop in re\ lation- ship with the field of bioethics (Lambeck et al. 2015).

Health Anthropology Theories As is typical in science generally, health anthropologists understand th\ e world in particular ways. One of the influences on how an anthropologist app\ roaches issues of health or illness is the particular theoretical framework or s\ chool of understanding a health anthropologist uses. There are several such frame\ works in health anthropology, although many individuals do not see themselves as \ adher- ents of any single perspective but rather take a more eclectic approach and allow the problem they are working on to shape the perspectives that they use. Other medical anthropologists consider themselves adherents or even advocates \ of par- ticular points of view. Indisputably, however, the perspective they brin\ g to their research will strongly influence the way a problem is approached, the questions that are asked, and the answers that are deemed sufficient and adequat\ e. Among the primary perspectives found in health anthropology are medical ecolog\ y, the meaning-centered perspective, and critical health anthropology. These ar\ e intro- duced here and given fuller examination in chapter 5.

Medical Ecology Rooted in both cultural ecology and evolutionary theory, this approach b\ egan with an emphasis on adaptation, defined as behavioral or biological changes at either the individual or the group level that support survival in a give\ n environ- ment, as the core concept in the field. From this perspective, health \ was seen as a measure of successful (or poor) environmental adaptation. In othe\ r words, a central premise of medical ecology initially was that a social group’s level of health reflects the nature and quality of the relationships that exist\ at three levels: Introduction to the Anthropology of Health 33 within the group, with other groups, and with the physical environment. Beliefs and behaviors that improve health or protect societal members from disea\ se or injury are adaptive. For example, there is the indigenous development of\ snow goggles that shield the eyes of Arctic dwellers from the damaging glare \ caused by the sun reflecting off ice and snow. This constitutes a small but i\ mportant health-related cultural adaptation of the Inuit people, as do the fur cl\ othing and ice houses of indigenous Arctic dwellers. Similarly, from the medical ec\ ological perspective, behavioral complexes, such as medical systems, including everything from shamanistic healing of soul loss to biomedicine treatment of heart \ disease, can be viewed as adaptive sociocultural strategies for confronting illne\ ss and con- tributing to the ability of a society to survive or even thrive. Similarly, the eco- logical approach is concerned with understanding how, and how well, cult\ ural and social formations address nutritional or other bodily needs. In rece\ nt years, as a result of dialogue with other perspectives, there has been movement\ toward the political ecology of health, indicating a recognition of the multipl\ e ways the environment is shaped by the unequal structure of relations within socie\ ties.

Meaning-Centered Health Anthropology The approach taken in medical ecology to the understanding of human biol\ ogy and behavior, as an interactive set of adaptations to ecological and soc\ ial chal- lenges, makes a lot of sense to many health anthropologists. Yet others \ have questioned aspects of this approach on the basis that from the perspecti\ ve of medical ecology, a disease, as is portrayed in science, is often treated as a natural object. Disease, in other words, is an object separate from human consci\ ousness and human cultural interpretation of the world (B. Good 1994). In turn\ , med- ical systems come to be seen in medical ecology as utilitarian social re\ sponses to intrusive natural conditions. As a result of these premises, in medical \ ecology cul- ture is absorbed into nature, and the work of health anthropology become\ s ana- lyzing the adaptive efficacy of health-related behaviors and beliefs. \ Lost in such understanding is a full appreciation of the human cultural/symbolic cons\ truction of the world we inhabit. Humans can experience the external material wor\ ld only through their cultural frames and thus diseases, as they are known, thro\ ugh body sensations or observations and measurements, by sufferers and healers al\ ike, are perceptions and sensations packed with cultural content. Even medical sc\ ience and biomedicine do not offer culture-free accounts of the physical world\ ; their understandings of disease or of the body also are cultural constructions\ . This is because both of these historically intertwined pragmatic ways of knowing\ the world emerged within particular cultural systems at particular points in\ the devel- opment of those systems, and they accept without thought or questioning \ many deep-seated cultural ideas and values derived from their encompassing cu\ ltural assemblage. For example, deeply embedded within and strongly supported by the day-to-day activities, theories, and organizational structures of bi\ omedicine and medical science are Western cultural notions of (1) individualism,\ namely, that each individual is distinct and is responsible for his or her succe\ ss or failure and self-improvement; (2) progress and the belief that history is a pr\ ocess of 34 Chapter 1 steady social improvement; and (3) the responsibility of action or a b\ elief in the appropriateness of changing the world to meet human needs and ourselves \ to meet cultural goals of maturity, wellness, and social success. Consequen\ tly, from the meaning-centered perspective, a goal of health anthropology is to “\ unpack” and analyze everything that makes up the health arena, from the experien\ ce of pain to the training and functioning of healers, as a set of systems for\ creating, experiencing, and communicating meaning in human life. Some researchers have emphasized that a meaning-centered approach, in addition to its analytic utility, has practical value in addressing heal\ th issues.

For example, a meaning-centered approach may have value in children’s\ can- cer treatment because it promotes the development of a way for caregiver\ s to understand and respond to children’s immediate experience of symptom distress, including the meanings and culturally influenced feelings children att\ ach to par- ticular symptoms throughout their illness trajectory (McClement 1998).\ Critical Health Anthropology During the early years of health anthropology’s formation, explanatio\ ns within the discipline tended to be narrowly focused on explaining health-relate\ d beliefs and behaviors at the local level in terms of specific ecologic\ al conditions, cultural configurations, or psychological factors. While providing ins\ ight about the nature and function of diverse medical models, the initial perspecti\ ves in the field tended to ignore the wider causes and determinants of human \ deci- sion making and behavior. Explanations that are limited to accounting fo\ r health-related issues in terms of the influence of human personalities\ , culturally constituted motivations and understandings, or even local ecological rel\ ation- ships, some health anthropologists began to argue, are inadequate becaus\ e they tend not to include examination of the structures of social relatio\ nship that unite (in some, often unequal fashion) and influence far-flun\ g individuals, communities, and even nations. A critical understanding, by contrast, in\ volves paying close attention to what has been called the “vertical links”\ that connect the social group of interest to the larger regional, national, and globa\ l human society and to the configuration of social relationships that contribute to the patterning of human behavior, belief, attitude, and emotion (Singer and\ Baer 1995). Consequently, what came to be called critical health anthropolog\ y (CHA) focused attention on understanding the origins of dominant cultu\ ral constructions in health, including which social class, gender, or ethnic\ group’s interests particular health concepts express and under what set of histo\ ric con- ditions they arise. Further, CHA emphasizes structures of power and ineq\ uality in health-care systems and the contributions of health ideas and practices to reinforcing inequalities in the wider society. Moreover, CHA focuses on \ the social origins of illness, such as the ways in which poverty, unhealthy living and working conditions, discrimination, stigmatization, violence, and fe\ ar of violence contribute to poor health, as well as the political-economic an\ d polit- ical-ecological sources of these causes of unequal health. The four auth\ ors of this book have been active throughout our respective careers in contribu\ ting to the critical health anthropology perspective. Introduction to the Anthropology of Health 35 From an applied perspective, critical health anthropologists seek to con\ - tribute to address questions such as: How are we to understand the natur\ e of industries and governance structures that facilitate disease by pollutin\ g (or allow- ing the polluting of) the environment and furthering global warming (w\ hich constitutes a severe and multidimensional threat to human health) or ot\ her ecocrises? What drives an economic system that makes possible the manufa\ cture and release of “killer commodities”—consumer products, such as \ those routinely advertised on children’s television that are high in fat, sugar, or s\ alt, that cause injury, illness, or death—onto the global market? What forces have pu\ shed, and what kinds of social relationships support, the biocommodification of \ nature, including the production of genetically engineered food crops and invasi\ ve and exploitive biotechnologies, like the global systems that lead to the mov\ ement of transplantable organs and tissues from poorer countries to richer countr\ ies and poorer donors to richer recipients? Contrary to what some have asserted, CHA does not take a “top-down approach” that denies people’s ability to resist and fight back \ against oppressive relationships that harm their health. Rather, critical health anthropolo\ gists argue that lived experience and “agency,” including individual and group decision making and action, are “constructed and reconstructed in the action arena be\ tween socially constituted categories of meaning and the political-economic forces that shape the context [and texture] of daily life” (Baer et  al. 2003:44). In other words, people develop their own individual and collective understandings and responses\ to illness and to other threats to their well-being, but they do so in a world that\ is not of their own making, a world in which inequality of access to health care, \ the media, productive resources (e.g., land, water), and valued social statuses p\ lay a significant role in their daily options. At the same time, critical health anthropol\ ogists do not explain all experiences of body/self disorder as an expression of social\ critique or resistance. Often, in fact, illness experience and the way it is handled\ socially serves only to reinforce rather than throw open to question existing structures\ of power. Additionally, while recognizing the fundamental importance of physical (including biological) reality in health, such as the nature of particular pathogens, CHA emphasizes the fact that it is not merely the idea of “nature”\ —the way external reality is conceived and related to by humans—but also the v\ ery physical shape of nature, including human biology, that has been deeply influen\ ced by an evolutionary history of social inequality, overt and covert social co\ nflict, and the operation of both physical power and the power to shape dominant ide\ as and conceptions in society and internationally through processes of glob\ alization (Whiteford and Manderson 2000). In the following chapters, we return to many of these ideas while emphas\ iz- ing the ways in which health anthropology—guided by any of the perspe\ ctives described here—actively seeks to understand health, health beliefs an\ d behav- iors, and healing systems and practices across time and place and to use\ this information in addressing health problems, conflicts, and suffering in\ the world.

We begin this process in the next chapter by examining what health anthr\ opolo- gists do, including the ways they approach problems, the kinds of proble\ ms they address, their collaboration with other health-interested disciplines, a\ nd their impact on the health arena. 36 Chapter 1 Discussion Questions 1. A core question of this chapter is “why have a health anthropol- ogy?” What do you think?

2. Why is health far more than a biological or medical issue; what other factors need to be considered to understand both how and why people get sick and how and why they get better (or fail to do so)?

3. Why do health anthropologists tend not to accept any particu- lar health-care system, including Western biomedicine, as holding a monopoly on useful health knowl- edge or effective treatment? Is this position justified?

4. What are some of the ways anthro- pologists have responded to den- gue? With Zika and other spreading mosquito-borne diseases, what factors might contribute to a major mosquito-related U.S. epidemic?

5. Why are social relationships, such as those between ethnic groups, and social structures that deter - mine access to resources and other things of value fundamental to health and disease?

6. Besides those mentioned in this chapter, can you think of any other cultural metaphors that ex- press how we think and talk about health and disease?

7. How do anthropologists engage the issue of ethics? Why are ethics important in health anthropology?

8. What are the key distinguishing features of critical health anthro- pology? What do you think about this orientation? 37 2 The distinctive approach of anthropology to research is to go out and se\ e what is actually occurring, and to talk to the people themselves. —John Janzen (2001:18) Introduction and Overview I n the previous chapter, a point we stressed is that health anthropologis\ ts are involved in a wide variety of health-related issues, places, and kinds o\ f work.

This chapter provides a closer examination of just what it is that health anthro - pologists actually “do” in these various settings. We begin by pro\ viding three additional cases of health anthropologists at work, including an explora\ tion of the kinds of problems they address and how they go about applying health\ an- thropology. Based on these cases, we then (1) discuss the range of issues health anthropologists study and the special focus they bring to their work bec\ ause they are anthropologists; (2) describe the distinctive health anthropology approach to research within the broad, holistic vision of our field; (3) examine the methods used in health anthropology research; and (4) explore applied activiti\ es in health anthropology beyond research.      Three Settings, Three Case Studies, Three Health Anthropologists Life and Death in Tanala Studying Indigenous Healing Sitting on the doorstep of Ranomafana National Park in the southern part of the island nation of Madagascar is the small Tanala village of Ranotsara (pseud- onym). Located in the Indian Ocean off the southeastern shore of Africa, to the east of Mozambique, Madagascar is well known for its shimmering forests and seething mass of biologically unique and richly diverse plant and animal\ species, such as ancient and exotic baobab trees, exceedingly slow-moving chameleons with strangely rotating eyes, and loud packs of lemurs, including the very rare Golden Bamboo lemur. Sadly, the Republic of Madagascar also is known as a land of aggressive deforestation. Ranomafana National Park, in fact, was estab- lished in 1990 with private and public funding from the United States as well as from international entities such as the World Bank. It is administered primarily What Health Anthropologists Do 2 CHAPTER 2 WHAT HEALTH ANTHROPOLOGISTS DO 38 Chapter 2 by U.S. citizens with the express goal of preserving biological diversity and eco- systems by linking conservation with improved standards of living for the people who dwell in and near parklands.

When health anthropologist Janice Harper arrived in the village to begin her research in April 1995, about 180 people, about a third of them children and teens, were living there, divided among thirty thatch-and-tin-roofed homes, most of which were rusted and leaking. Surrounded by irrigated rice fields, the village constituted a manmade island nested on hard-packed reddish dirt. Harper had come to study the indigenous use of medicinal plants and nontraditional medi- cines, customary topics of health anthropology research, but right from the start events on the ground began to challenge and reshape her research plans.

The Cultural Construction of Hygiene Harper initiated her research project with door-to-door introductions with all the villagers, followed by a set of “invasive but excessively polite demographic questions” (Harper 2002:166). Subsequently, she interviewed people about their health problems, understandings of health issues, and acquisition and use of forest and Western medicines, among other topics. She observed and par - ticipated in daily village activities and filled her notebooks with deta\ iled accounts of what she saw and heard. As she lived among the villagers, witnessing their routines in the fields and around the village, and casually interviewed them about their use of healing plants and other mundane issues of day-to-day\ vil- lage life, Harper realized that the villagers’ conceptions of health and cleanli- ness were different from her own, Western, middle-class ideas. Attempting to be ecologically sound, she tried to bury all her garbage, from crumpled papers (reflecting false starts in her writing efforts) to the tin cans and plastic bags from the used-up Western products she had carried with her to the field. The villagers, who produced little if any garbage, were astonished by the amount she produced—which, very likely, was far less per day than the average mid- dle-class home in the United States—and they believed her to be very rich to be able to make so much garbage. Indeed, many of the things she discarded, such as used-up glass bottles, they coveted as useful containers. Everyt\ hing else that she buried the pigs rooted up and scattered about. Washing was another issue. In a place where a bar of soap costs a full day’s wage, water doesn’t run from a tap, and the latrine consists of the spaces between the trees in the nearby coffee grove, keeping clean is a constant challenge that is com- plicated by the fact that daily labor—from sunrise to sunset—in the rice fields means standing in calf-deep mud that is thick with worms and feces, whil\ e work on the nearby hillside gardens involves toil in the blazing sun. Most peo- ple’s clothes were tattered and their bodies scrawny but strong from daily man- ual labor. As for the children, Harper found that almost all had bloated bellies as a result of worm infestation, their skin was encrusted with lesions caused by scabies (a microscopic burrowing insect), their legs and arms were marked by large boils, their ears were leaking yellow pus from infections, and their bodies What Health Anthropologists Do 39 were mostly underweight, and yet they were active and playful and filled the village with their laughter.

In the Company of Death Harper also was struck by the frequency of sickness and death around her.

Indeed, a woman who sought employment from Harper on the anthropologist’s first night in the village had died by the following morning. During her fourteen months in the village, eighteen people died, a disturbingly high mortali\ ty rate of almost 100 per 1,000 population compared with just more than eight deaths per 1,000 population in the United States.

Her fieldwork ultimately ended as it began with the death of a villager. On the morning of her departure—under pressure from park officials not to express any criticism of the park or to imply that the park was a factor in vill\ age morbidity and mortality rates—Harper (2002:235) was awakened “not to the e\ erie cries of the lemurs,” which had enchanted her mornings and nights in Ranotsara, but to “the ghostly cries of women wailing for the dead. Maily, a young woman in her twenties, had died during the night.” Writing Up On her return to the United States, Harper wrote a book titled Endangered Species: Health, Illness, and Death among Madagascar’s People of the Forest to document her findings and to show that while the people she studied use plants, barks, and roots from the forest to treat (but rarely cure) debilitating diseases that are readily cured with pharmaceutical medicines, the latter are usually inaccessi- ble. Harper (2002:3) argued that “their continued reliance on the forest’s botany for their health care is less conditioned by their ‘culture’ than it is by social inequalities that have rendered them cash poor.” Even the forest at their doorstep is controlled by others, turning their social disparities into health disparities, an issue of keen interest to health anthropologists that is examined in chapter 4. Rather than exist- ing in an exotic village with a traditional way of life sheltered by dense forest from the fast-paced and changing world system around them, the lives of the peo- ple of Ranotsara, Harper found, are shaped, although not narrowly so, by forces beyond their reach and certainly beyond their control. Harper seeks to reveal what can happen in contemporary development, including the ecological develop\ ment movement, when people are not treated as part of the natural environment that is being protected, issues that are addressed more fully in chapter 5. To make her points, Harper relies not solely on her own research findings but also on an exam- ination of historic records, economic reports, and population data.

Studying Surgeons Problems at Meadowbrook Many miles from Ranotsara and seemingly a world away from its humid green landscape lies Meadowbrook University Hospital (pseudonym) on the outskirts 40 Chapter 2 of one of Canada’s largest cities. With 800 patient beds, 120 of which are reserved for surgical patients, Meadowbrook doctors perform 15,000 opera- tions each year. As a university hospital, in addition to providing health care to patients, Meadowbrook is a teaching institute and thus is home to a steady and changing flow of medical and other students seeking to become health-car\ e professionals, and, further, it is a health-care research center oriented to increas- ing the fund of biomedical knowledge.

Despite its sanitized veneer of orderliness and control, Meadowbrook had a problem. The hospital began to receive urgent complaints from surgical residents in their final stage of training that the staff surgeons who were their teachers and supervisors were not spending enough time training them to be surgeons. In response, as noted in chapter 1, Pearl Katz, a health anthropologist, was invited by the chief of the Department of Surgery to carry out a study that woul\ d help resolve the problem. Katz realized that the study held the potential to be of even greater importance than the immediate needs of the Department of Surgery.

Health anthropology, which views biomedicine as ethnomedicine—if of a special sort, namely, a medical system that has gained global importance and a domi- nant position in terms of other ethnomedical systems internationally—is keenly interested in understanding how biomedicine works, including its roles in soci- ety, its worldviews and underlying cultural models, social structures, and variet- ies across time and place.

Expect Rejection When Katz (1999:16) began her study, she was “warned by friends and col - leagues that [she] would have difficulty getting accurate information on what surgeons did.” Katz’s anthropological colleagues assumed that the surgeons, being privileged and, relative to patients and researchers at least, rather pow- erful, would limit her access to information, especially to unfettered backstage glimpses of their lives and behaviors. Certainly other researchers have had trou- ble gaining full access to biomedical practitioners. In her own study of\ surgeons, for example, health anthropologist Joan Cassell—a colleague who encouraged Katz to publish her findings—was once sternly asked by a surgeon after an operation to which a nurse had invited her to observe, “What’s an anthropologist doing studying surgeons?”—to which she glibly responded, “Well, there were no other primitives left” (Cassell 1998:10). Cassell’s experience notwithstanding, Katz found that the surgeons extended her an extraordinary level of trust and openness; they appeared to her to want to be understood.

Instead, Katz found herself challenged by her own attitudes toward sur - geons. It was much easier for her to identify with patients and she was \ criti- cal of the disparaging attitude surgeons expressed about the concerns of their patients. She was shocked to find that they referred to an especially frightened patient as the “beast” or the “colon.” Only over time, after\ observing many oper - ations, did Katz realize that she too was depersonalizing patients and why this What Health Anthropologists Do 41 was a useful mechanism that enabled surgeons to “protect themselves against the [emotionally burdensome] experience of empathizing with the personal anguish of patients” (Katz 1999:8). Katz also found herself envying\ the power held by surgeons and came to realize that to some degree such envy fuels dia- tribes against the status of surgeons found both in the popular mass med\ ia and in some social science analyses.

Following Doctors In her day-to-day work on the study, Katz focused intensely on six senior sur - geons. With each of these key informants she spent approximately three con- tinuous weeks, from the moment they arrived in the hospital early each morning until they left the hospital about twelve hours later, a method known as “shadow- ing.” As one of the doctors she studied noted in introducing her to a colleague, “Look, I’ve got a girl following me around all the time, taking down everything I say” (Katz 1999:7).

Over time, Katz (1999:91) developed a number of keen insights about “\ sur - geon culture,” including the fact that while they act jovial and gregarious in the company of their colleagues, surgeons tend to carefully protect “information about themselves, their patients, their operating loads, operative techn\ iques, referral sources, levels of specific knowledge, specific expertise (particularly deficits in knowledge and expertise), income, and doubts and concerns about medical decisions,” in other words, anything that might allow another surgeon to have the upper hand in dealings with them. Feelings of competition with other surgeons, in short, were as strong as or stronger than any sense of collegiality and collaboration. This underlying feature of surgeon culture, Katz found, was a critical component of why residents felt that hospital staff surgeons were not spending adequate time training them for their jobs as surgeons.

Folk Illness in Haiti Illness and Identity Far to the south of Meadowbrook University Hospital, on the Caribbean island of Haiti, lies the rural village of Jeanty (pseudonym), tucked into the foothills above the Cayes plain, once one of the wealthiest sugar-growing areas of the world. The village itself is hilly and rocky and was probably first populated during the early nineteenth century by freed slaves fleeing plantation labor in the early years of Haitian independence from colonial France. Little more than a cluster of small tin-roofed houses strewn along a grid of unpaved streets, Jeanty is home to three thousand people with a total population of almost twelve thou- sand in nearby hamlets. With American funding, CARE, a relief agency (one of many in Haiti), had installed a potable water system in the village, an\ d it was with the assistance of CARE that Paul Brodwin, a health anthropologist, had arrived there in 1987 to study folk conceptions of illness, healing, and mortality. 42 Chapter 2 Specifically, Brodwin examined the crisis of illness as a fundamental social expe- rience during which people commonly rework their social identities and confront the contradictions of their life experience, health-related processes addressed in chapter 3.

The Language of Research Brodwin’s research methods included participant observation of routine health-related activities among village members, semistructured interviews with village residents, attendance at community religious and healing rituals, the col- lection of life histories of village members, and interviews designed to\ record detailed narratives of actual illness experiences. He was aided in this effort by being a novelty for the villagers: only a handful of outsiders have ever lived in the village, and thus locals were interested in talking with him. Initially, Brodwin had an assistant, a young man from the village, but before long his ability to speak Creole—the language born of the merger of French and several languages from West Africa—was sufficient to conduct his own interviews.

Choosing a Healer In his study, Brodwin addressed an issue that is central to health anthropology (see chapter 7): in contexts of medical pluralism (i.e., coexistent a\ lternative heal- ing systems), how do people make decisions about which ethnomedical sys\ - tem to go to—for what health issues and why—and what actually happ\ ens as patients and healers interact? When they get sick, people often must choose between multiple and competing healing traditions. This is the case both in the small-scale communities where anthropologists commonly have worked and in the urban centers where many anthropologists now do their research. To help answer these questions, Brodwin observed more than fifty consultations between patients and herbalist healers and about twenty interactions bet\ ween patients and houngans (male healers in the Vodou folk health-care system). In each case, he carefully recorded his observations of what happened, including the nature of the problem brought by the patient, healer questions and actions, patient responses, the context and tone of the interaction, and the issue of pay- ment. For example, about one consultation by a Haitian patient suffering from painful muscle aches and body fatigue, Brodwin (1996:134), who accompanied the patient, named Louis, to the healing session, recorded, André [a houngan known to the patient] greeted us at the door, and after the necessary introductions, led us into his small consulting room and sat at his table. It was covered with a heavy red cloth, and an assortment of small bottles filled with remedies lined the back. . . . As André settled in his chair, he lit an oil- wick lamp. . . . [After a while] André began to moan and gasp for air between coughs which wracked his entire upper body. . . . He soon began to rock back and forth and softly whistled, a serene smile on his lips. . . . From this moment on until the end of the consultation . . . we communicated only with his lwa [the spirit being named Byenzomal that had possessed André and began to speak What Health Anthropologists Do 43 through him]. . . . When he had finished the divinations [to deter\ mine the source of Louis’s symptoms] and given to Louis the names of several [folk] remedies to purchase, Byenzomal rang the bell . . . and announced “We’re through.” Studying Exotica To his fieldwork project, Brodwin brought a strong curiosity about the exotic, one that was not disappointed by scenes such as the one just described. \ As Brodwin (1996:129) admits, “Years of graduate training in anthropology had not suppressed my typically American fascination with the exotic side of popular Haitian religion.” To his initial disappointment, however, he was frustrated in this desire at every turn. Several months passed before he was finally able to make contact with and begin interviewing a houngan.

In his interviews with village members, Brodwin came to realize that while people may consult houngans for their pressing health problems, it is not with- out a degree of fear of the malign ability of these specialists to “send sickness.” Fear—although of a different sort—plays a similar role in the hesitancy many people in the United States feel about seeing a dentist or having an ope\ ration.

As Brodwin learned, ambivalence, uncertainty, and moral struggle are often crit- ical features of illness and healing, lessons learned by health anthropologists working in diverse social and cultural settings.      A Case Study Having Impact As Erickson (2003:3), whose work in health anthropology addresses repr\ oduc- tive health issues, points out, Medical anthropology has a broad mandate—to understand and interpret hu - mans, their diseases and illnesses, and their medical systems. Many medical an- thropologists also take on the responsibility of making their research useful for clinical or health educational applications, for influencing public health policy, or for effecting social justice.

Through this brief examination of the fieldwork of three different health anthropologists in different parts of the world and with very different \ field sites and populations, as well as different research questions and methods (i\ ncluding, in addition, the three examples provided in chapter 1), we begin to grasp \ just what it is that health anthropologists do to fulfill the discipline’s br\ oad humanitarian and scientific mandate. Some of what they do, indicated by the six cas\ e studies presented thus far includes (1) at times, focusing their research and \ applied efforts directly on specific diseases (e.g., cystic fibrosis or dengue), and in other cases, concentrating on particular healing traditions (or multiple traditions \ in inter- action), to reveal underlying factors missed by less intensive, less field-oriented 44 Chapter 2 approaches to research; (2) addressing gaps in health-care services th\ at often only are revealed by up-close, ethnographic research; (3) seeking to understand the provider-patient relationship and the nature of the healing process; (4\ ) investi- gating local health beliefs, practices, and concerns to help shape publi\ c health efforts to match their target audiences and promote community involvement; (5) working “on the ground” among people as they live their everyday lives in order to spot and develop understandings of risk behaviors (and their causes) as well as risk contexts that promote unhealthy behaviors and exposures; (6) t\ rying to understand the social origins of illness and use this information to mak\ e specific policy change recommendations to reduce health risk; (7) determining the contri- bution of social inequality and injustice to inequities in health outcom\ es; and (8) exploring biosocial and socioenvironmental interactions to better compre\ hend the making of wellness and disease relative to other species, environmental \ features, and the climate. Ultimately what health anthropologists do is seek to im\ prove health, generally with groups that face the biggest health challenges an\ d threats.

What Health Anthropologists Study A Diverse Discipline In the role of applied social scientists, health anthropologists commonl\ y seek to answer practical questions about the nature of health, illness, healing \ systems, and related matters across cultural systems, populations, and social contexts.

These questions derive from various sources. Some reflect ongoing deba\ tes and discussions generated at anthropology (and other health) conferences a\ nd in the published literature, primarily books and journals but also government o\ r other reports, policy papers, and other documents of the discipline and relate\ d fields.

Others are raised by institutions, government bodies, or communities tha\ t seek the help of a health anthropologist in addressing pressing issues. Still\ other ques- tions arise because of changes in the world that impact health. For exam\ ple, the rapid increase in electronic communication (especially cell phones and \ computers) has influenced health-related behavior in various ways (e.g., the rap\ id electronic accessing of health information on the internet). Increasingly, health \ anthropolo- gists, like other researchers, have asked research questions about the i\ ntersection of health behavior and electronic communication including social media. \ During the 2014–2016 Ebola epidemic, for example, Olivia Marcus and Merrill \ Singer (2016) analyzed the appearance of an internet meme known as Ebola-chan\ that began to show up on various internet sites. This unexpected anime character— an anthropomorphic internet representation of the Ebola virus—combined the appearance of girlish innocence and an inversion of the meaning of carin\ g (in the sense of loving someone to death) with morbid imagery to encapsulat\ e con- flicted social responses to a lethal and fast-spreading epidemic in th\ e digital age.

Drawn and posted anonymously, the meme appeared on various internet site\ s, garnered a range of posted reactions, triggered the creation of various other infectious disease memes, then faded away as the epidemic peaked and beg\ an to recede in the global social imagery. A similar internet response does no\ t seem to have accompanied the 2015–2016 Zika epidemic despite the widesprea\ d fear What Health Anthropologists Do 45 generated by the linkage of this mosquito-transmitted disease with micro\ cephaly and fetal malformation. As these examples suggest, the internet is a dom\ ain of health-related behaviors and communication in critical need for enhanced health anthropology research and understanding. Also of concern to health anthropologists is the role of governance in t\ he framing of global health issues. Governance refers to how a governing bo\ dy or other institution with sway in society views its mission and carries it \ out through policies and actions. Part of governance is what Michel Foucault (2008)\ called governmentality or the way governments and other social control institutions try to shape their citizens to be particular kinds of people or, in the \ case of the governmentality of hospitals and clinics, particular kinds of patients. \ The U.S.

government, for example, stresses the making of responsibilized citizens\ who see issues like illness, health insurance, unemployment, and poverty as \ not being the responsibility of the state or society, but instead as the private b\ urden of individuals and families. Consequently, there is a strong and often mora\ listic emphasis in American culture on self-care, often actualized as care through con- sumption (buying particular foods, joining gyms, taking yoga classes, purchasing the right gear for all manner of sports). In research on emergent popul\ arized views on cancer, for example, adopting a healthy lifestyle is being defined as a way of preventing disease, based on the understanding that the epidemiol\ ogical literature firmly demonstrates the role of factors such as weight, die\ t, and exercise on cancer risk. But, in fact, “scientific findings on the cancer/\ lifestyle link” show that they “are incomplete, ambiguous, and internally contradictory”\ (Bell and Ristovski-Slijepcevic 2015:219). At the global level, health anthropolo\ gists are examining global health governance and the ways global health issues are\ framed.

This concern stems from recognition that how health problems are conceiv\ ed will shape global efforts to respond to them. Without doubt, health anthropologists have diverse points of view and do\ not by any means fully agree about what the key questions of the discipline are. Some health anthropologists, those interested in the experience of \ illness, focus much of their attention on humankind’s phenomenological encounter with being sick, asking questions such as what does illness mean to peop\ le in particular social roles, sociocultural contexts, and social settings? Wh\ at is the internal lived experience of illness like for sufferers and what shapes \ this expe- rience? What impact does illness have on their identities, relationships\ , and values? Concern about answering such questions has led some anthropologi\ sts working on health issues to adopt the concept of subjectivity. Subjectiv\ ity refers to the internal thoughts, feelings, and worries of people as well as the\ ir intent, desires, and images of self—in short, the emotion-laden fabric of the\ ir inner lives in social context. Subjectivity, from the anthropological perspective, i\ s not an individual or private state, but rather involves how people in common si\ tuations, facing common challenges, develop overlapping and meaningful ways of bei\ ng, knowing, and experiencing in the world (Good 2012). Central to the not\ ion of subjectivity is examination of behavior, including health-related behavi\ or, as a dynamic and fluid process, an emergence, rather than one narrowly cons\ trained by cultural conventions (Abadía-Barrero 2011). This means a study o\ f behavior as conscious action relative to others and inner lives as products of in\ teraction 46 Chapter 2 and intersubjectivity. A study of gender and mental health treatment in \ different clinical and home settings in northern India (Pinto 2014), for example, focused on how women experience the vulnerabilities of love in their minds, thro\ ugh their bodies, and as part of their social world of interactions. In both\ the Hindi and Urdu languages, in fact, love and madness are both considered forms \ of nasha or intoxication. Loving the wrong person in an intense, driven way, cra\ zy love, is constructed culturally as a destructive force that shattered th\ e wellness of not only the women patients Pinto studied but their families as well.\ During her fieldwork, Pinto herself faced a jarring personal crisis, which sh\ e writes about as an intersubjective aspect of her research experience, a broken mirror\ that reflected the broken inner worlds of the women about whose lives her w\ ork poignantly examines. Other health anthropologists are more interested in how people make deci\ - sions about what to do when they are ill, including their help-seeking s\ trategies, how they select among alternative healing systems or combine different t\ ypes of treatment, and the role of significant others in shaping these process\ es. Alterna- tively, there is keen interest in both the nature of the patient-healer \ relationship and the relative effectiveness of different approaches to treatment amon\ g various health anthropologists. Finally, some health anthropologists are especia\ lly con- cerned with the role of environmental, social, political, and economic factors in illness. In this book, we engage all of these issues of concern to the fi\ eld by way of introducing the range found within the discipline. Further, health has a global research mandate. As seen in the examples that have been provided, some health anthropologists work in rural villa\ ges in developing nations, others conduct their studies and applied work in mod\ ern hospitals, while others carry out their research on the street corners o\ f cities large and small, or even on the internet. Many health anthropologists wo\ rk in quite different settings over the course of their careers. A complete co\ mpilation of all the topics health anthropologists have addressed and all the plac\ es they have conducted research or implemented programs would be surprisingly long and varied. The discipline requires that its practitioners have a good s\ ense of our changing world and the dynamic domain of health in human societies, and \ even beyond humans to interacting species that may be the source of zoonotic \ human diseases or cures.

Studying the Life Course Another reflection of the broad mandate of health anthropology is the \ work done by members of the discipline across the various stages of the human\ life course, from birth (or even before, in terms of reproductive health) t\ o death.

In all societies, reproduction and reproductive health are heavily inves\ ted with cultural meanings and values. Women’s menstruation, likewise, is comm\ only a focus of cultural elaboration; menstrual blood often is seen as being especially charged and possibly polluting. The process of giving birth also is cult\ urally shaped and managed in all societies according to group understandings of\ appropriate birthing behavior. With her classic anthropological study Birth in Four Cultures, Brigette Jordan (1993) helped launch the anthropology of birth What Health Anthropologists Do 47 and reproduction as a subfield of health anthropology. Work in this ar\ ea has shown that cultures develop distinct beliefs, meanings, and associated p\ ractices around pregnancy, delivery, and the treatment of babies during the postp\ artum period. Further, researchers working on this topic have demonstrated tha\ t there is a need for an examination of birthing within structures of power in h\ ealth care and in society generally, and in light of both women’s culturall\ y influenced priorities and factors such as their attitudes toward pain, fear, stress\ , and anxiety.

In biomedicine, for example, the full medicalization of childbirth—ch\ aracterized by (1) the use of high-tech machinery for monitoring the birthing proc\ ess that begins early in the pregnancy and continues through delivery, (2) freq\ uent use of surgery to both widen the birth portal and remove the baby, and (3) wi\ despread use of medications to deaden pain or speed up the birthing process—ha\ s led to the use of the term “technocratic birth” to characterize having a baby in Western society (Davis-Floyd 1992). An informative study of the role of social\ class and educational influences on women’s birthing behaviors in Chile focus\ ed on the period before delivery (Murray 2012). Rather than there being a single Chilean pattern of birthing preparation, there were different patterns structure\ d by social class and access to differential material resources. However, as the tim\ e of birth approached and women’s sense of vulnerability and risk increased, the\ class strat- ification in attitudes about the medicalization of birth collapsed int\ o a general, cross-class acceptance of the choices made for women by the biomedical s\ ystem.

Fear and uncertainty came to override prior choice and led to acquiescen\ ce to socially enforced biomedical authority. By contrast, in many societies, \ traditional birth attendants (i.e., senior women with considerable personal and app\ rentice experience in birthing) provide the primary support to a woman in deliv\ ery.

Low-technology, midwife-assisted birthing systems have resisted the spre\ ad of technocratic birth, often with anthropological support. An applied approach to the issue of birthing has led to anthropological work on issues such \ as teen pregnancy as a health and social problem, including showing why teen gir\ ls often view pregnancy as a sought-after social status (Erickson 1998). Simila\ rly, health anthropologists have studied children’s health and have been active i\ n applied projects such as breastfeeding promotion. Some anthropologists, for exam\ ple, became very involved in the effort to challenge the global promotion of \ commer- cial infant formula by Nestlé Corporation and other companies as a re\ placement for breast milk (e.g., Penny Van Esterik 1989). In many settings, manufactured formulas, they have argued, are detrimental to children’s health and \ sometimes, if clean water for mixing the formula is not available, even life threateni\ ng. Breast- feeding, by contrast, not only provides a nutritious food for babies; it\ also passes important maternal immunities to diseases on to young children. Chapter \ 8 considers the human dimensions of the emergence of biotechnology, the ro\ le of biocapital and the emergence of markets for body tissues, and the growin\ g array of bioethical issues in which health anthropologists are now engaged. At the distal end of the life course, since the 1950s anthropologists ha\ ve also paid considerable and increasing attention to aging. Research in this ar\ ea has shown that old age commonly is marked by a shift in a person’s role i\ n society, such as a significant reduction in work responsibility, as well as cha\ nges in social status, including, depending on the local setting, coming to be viewed v\ ariously 48 Chapter 2 as a valued storehouse of important cultural knowledge or as out of touc\ h with the contemporary world. The nature of these transitions varies because t\ he meanings attached to being “old” are culturally constructed in lig\ ht of other fea- tures of a society. In a fast-paced, rapidly changing, and globalizing s\ ociety, the knowledge and experiences of elders may be devalued; by contrast, in soc\ ieties that look to tradition as a guide to the present, growing old may be acc\ ompanied by a gain in social stature. Increasingly, however, as the global market\ (e.g., labor migration) has had its impact, there have been significant but locall\ y varying changes in intergenerational relationships. In China, for example, where\ the elder population has been growing rapidly and becoming a higher percentage of \ the total population, traditional values of elder respect, family support, a\ nd obliga- tion to caregiving face new challenges and moral dilemmas (Sheng and Se\ ttles 2006). Broad economic and social changes have weakened the social found\ ations of family care for elderly parents and elderly expectations about being \ cared for later in life by their grown children. Parent-child relationships in Chi\ na have become less hierarchical in recent decades, and, as contrasted with the \ past, elder parents exert shrinking influence on their grown children’s life de\ cisions. Elder parents, in fact, are contributing to their grown children’s independ\ ence through their growing role in taking care of their grandchildren. While family s\ upport and caring certainly have not disappeared, remain expressed values among par\ ents and children alike, and include both emotional and financial support, \ increasingly the government has played a role in elder care through the provision of \ nursing homes, day centers, and elder entertainment centers. Another topic of concern in the anthropology of aging is medicalization.\ For example, since the introduction of Viagra (also see chapter 7 for d\ iscussion of this drug), there has been a biomedically driven redefinition of decr\ eased erectile function accompanying aging vis-à-vis the disease diagnosis known as \ erectile dysfunction. The medicalization of older people’s sexual health bring\ s together Western social discomfort in response to aging with the valorization of \ penetra- tive sexual practice as “normal sex.” In this context, drugs like \ Viagra provide biomedicine with the possibility of improving health, defined in this \ culturally influenced context as youthful sexuality. Such drugs are an enormous s\ ource of profit for the pharmaceutical industry (e.g., Viagra produced almost \ $8 billion in revenue between 2012 and 2016 [Statista 2017]). Moreover, they are m\ ar- keted globally and represent the spread of Western cultural views of agi\ ng and the body, which reduce the aging process and the lived experience of the\ elderly to a form of fixable mechanical breakdown. However, not all men buy in\ to this redefinition. Health anthropology research based in the urology depart\ ment in a government hospital in Cuernavaca, Mexico (Wentzell 2013), for examp\ le, found that male patients understood their decreasing erections as both n\ atural and a physical sign that it was time for them to move past a youthful fo\ cus on penetrative sex and live a more “mature” masculinity based on emot\ ional interac- tions with their families. This decision, encouraged by their wives, enabled these men to embrace local cultural values pertaining to respectable older man\ hood.

Such research demonstrates the continued impact of local cultural values\ on gen- dered life-course behaviors in a globalized world. It also represents th\ e growing What Health Anthropologists Do 49 concern that a consciously gendered focus on health not be limited, as i\ t often has been in health anthropology, to women’s health issues. Applied work in the anthropology of aging has focused on many issues, in\ clud- ing helping to give voice to elders whose needs and capacities have been\ overlooked in society. Applied health anthropologists have developed ties with an i\ nternational movement working to promote elder-friendly communities and the promotion of well-being throughout the life course. Dying and death are also issues o\ f concern in health anthropology; they constitute profound arenas of human experie\ nce, thought, and emotion. In contemporary health anthropology studies, dying\ and death are viewed as “subjects without clear boundaries, and any analy\ tic explora- tion of those themes now problematizes their definition” (Kaufman \ 2004:245) rather than viewing them as clear-cut biological states. In other words,\ death and dying must be understood in sociocultural context because what it means to die in one society may be quite different from what it means to die in another.\ Conducting Research: A Peculiarly Anthropological Approach Holistic, Field-Based Understanding In conducting research, health anthropologists tend to assume that the i\ ssues of immediate concern to them are embedded in wider sociocultural systems an\ d are intricately interconnected with many other aspects of social life and wi\ th com- plex social environmental contexts. As a result, they tend to cast a wid\ e research net and ask a broad set of research questions. To carry out their research, health anthropologists usually marshal a number of qualitative and quantitative\ methods for the collection of health-related data (e.g., see the seven-volume set Ethnog- rapher’s Toolkit, which fully describes the methods used by many health anthro- pologists in their research [Schensul and LeCompte 2010]). Moreover, he\ alth anthropologists generally seek to move out of the university or other in\ stitutional setting in which they are employed to gain direct and intimate access to\ the daily lives and activities of the people under study. Further, they often spen\ d long periods of time in these field settings observing and participating in the flow of life. This is an approach to research known as ethnography.

Ethnography Ethnography is the name of the core research strategy in health anthropo\ logy.

It involves the immersion of the researcher or team of researchers into \ the social space and lifeways of the people under study. As part of this eff\ ort, health anthropologists seek to participate (to varying degrees) in the normal\ social life of the group under study. While not all research in health anthropo\ logy is ethnographic, there is a generally shared sense that ethnography offe\ rs keen insights about health and behavior that are not easily acquired through \ other means. Rather than a highly controlled and sharply focused approach to d\ ata collection, ethnography focuses on issues of concern within their natura\ l social context and in terms of how they are seen and experienced by group membe\ rs. 50 Chapter 2 Choosing Risky Behavior In studying health issues, health anthropol- ogists often use ethnography to address difficult questions or seek to make sense of puzzling or misunderstood behaviors.

Elisa Sobo, for example, was confronted with the challenge of understanding why people who know about AIDS and routes of infection nonetheless regularly participate in risky behaviors, such as not using condoms during sex. This is an important problem for public health because it is clear that simply teaching people about AIDS as an infectious dis- ease does not eliminate risk; the disease continues to spread. In the United States, ethnic minorities have been disproportion- ately affected by AIDS since cases were first identified, and constitute the major - ity of new diagnoses in the ongoing epi - demic (Kaiser Family Foundations (2017).

In her study of risky behaviors among impoverished and socially disadvantaged women in Cleveland, Ohio, Sobo (1995) concluded that people who know about AIDS often act as if they are not at risk, a puzzling discovery that needed explana- tion. AIDS-risk denial, she found, appears to be rooted both in a cultural tradition that values monogamy and personal responsibility and in the actual position of women in society generally and relative to men. Thus, the women whom Sobo studied idealized and desired long-term monogamous romantic relationships and loyal, committed partners. The under - lying cultural logic that supported this heartfelt desire is this: good women get good men, and unworthy women get bad men. If you are a good woman, then you should be able to trust your partner. This attitude reflects very basic cultural ideals in American society and leads people to interpret life course and outcomes in terms of how hard people work and how committed they are to achieving their goals. Simply put, those who succeed are seen as having worked hard, and those who do not are seen as slouches. Having an untrustworthy male partner, in short, implied that a woman did not deserve better, putting her very identity and sense of personal self-worth at risk. Like others in the wider society, the women whom Sobo studied seek good relationships with good men, thereby prov- ing to themselves and their social networks that they are, indeed, women of value. As a result, with their main partners, the women do not use condoms (because as good women they can trust their partners not to have sex with others). One consequence of poverty and social discrimination, however, is that the potential partners whom women like those Sobo studied are likely to meet tend to have comparatively high rates of unemployment and underemployment, lack of health insurance, and limited other resources. As a result of an inability to suc- ceed economically in society and to reap the psychosocial benefits of being suc- cessful in one’s own eyes and in the eyes of peers, it is a special challenge for poor men to feel good about themselves and about their own worth as human beings.

As a psychosocial substitute for economic achievement and hence as a salve for the potential sense of failure in a success-driven society, street culture, in fact, tends to sup- port “sexual achievement”—that is, having multiple partners over time or even at the same time—as a sign of success. Thus, one can still have a sense of achievement in life and the experience of having admira- ble qualities, even if it is acquired through a What Health Anthropologists Do 51 Over time, ethnographic researchers are able to glimpse behind the publi\ c masks and front-stage performances of social actors to backstage and often hid\ den arenas of experience and social interaction. In this way, they are often\ able to develop understandings of behaviors that might otherwise appear irrational, meaningless, or inscrutable, or might otherwise go unknown. For ten years, Andrew McDowell (2016) engaged in the ethnographic study in India of “Bengali doctors,” unregulated popular healers w\ ho do not have medical degrees but make use of biomedical medicines (e.g., inject\ ions and intravenous transfusions of antibiotics, stimulants, painkillers, vitami\ ns, and fever reducers, often in multidrug cocktails). These healers are said by thei\ r biomedical critics to treat immediate symptoms but not underlying disease, potentia\ lly caus- ing longer-term harm to their patients. One of McDowell’s study parti\ cipants was a Bengali doctor named Mohit. He accompanied Mohit on fifty house \ calls to treat patients and spent countless hours with him at his clinic, obse\ rving and chatting about medicine, current events, and their respective lives. McD\ owell found that conversations about Mohit and health were commonplace among the people in southeast Rajasthan, where he carried out this part of his\ research.

He heard such conversations in public places, like the village hand pump\ , bus stand, and squares. McDowell joined these conversations and carried out \ inter- views with seventy local public health providers. McDowell found through his deep and prolonged ethnographic immersion in everyday life and popular health treatment that while Mohit and fellow practitioners treat symptoms, they do so within a cultural frame that is meaningful to\ them and their patients. While their treatment practices may appear irrational in\ the eyes of nonmainstream method, although one that is not entirely beyond the mainstream; fan- tasies of multiple sexual exploits are hardly limited to the poor. Consequently, poor men and women are pushed by social forces and cultural val- ues to be at cross-purposes, a tension that finds expression in high rates of divorce, failure to marry, and intimate partner vio - lence. In their effort to achieve monogamy and the psychological benefit of feeling that they merit a good man, Sobo argues, poor women are pushed to see their male partners as more loyal and more deeply committed than social circumstances allow them to be. Thus, they may begin prematurely to assume that their partners are not seeing other women. In this con- text, the decision not to use condoms affirms a woman’s desire to feel worthy of a dependable man. Various behaviors rein- force this decision. Sobo (1995:99) notes, “A man who gives his wife or girlfriend gifts, services, or money lives up to—or at least begins to live up to and implies he intends to live up to—the cultural ideal of the male partner as breadwinner or provider and as a woman’s protector.” Under these con- ditions, stopping condom use is an act of commitment, an expression of trust, and an investment, through potentially having a child together, in a long-term partner - ship. The problem, however, is that most women who get AIDS are not infected during one-night stands with poorly known sexual partners because condoms tend to be used in such situations. Rather, they are infected with HIV by longer-term partners, people they trust with whom they are hav- ing sex without a condom. 52 Chapter 2 biomedical physicians, they are able to return patients to a satisfying \ feeling that they have a well-functioning body with steady breathing, cycles of hunge\ r and sati- ety, and oscillations between tiredness and invigoration. In short, they\ reestablish a sense of organic and mechanical productivity from the perspective of the\ ir patients, until something else throws their bodies out of their normal cycling pat\ tern.

Complex Sociocultural Tapestries In explaining health-related behavior, health anthropologists pay attent\ ion to the interplay of a wide range of cultural, social, hierarchical, psychologic\ al, environ- mental, and even biological factors. Only by showing how all these weave\ together in complex tapestries, something that the ethnographic methods of health\ anthro- pology allow, can we really understand why people do what they do, belie\ ve what they believe, and get sick or stay well. In thinking about Sobo’s AID\ S study, one advantage of this perspective is the realization that sexual desire—which is often condemned in moralistic discussions of sexual risk—must be reframed “\ from an individual to a collective phenomenon” (R. Parker 2009:xiv). Cultur\ e provides a frame of reference “though which sexual meanings are organized—and\ in relation- ship to which conflicting and contrasting sexual scripts are produced \ and repro- duced” (R. Parker 2009:xiv), and these, in turn, are shaped by othe\ r factors like social hierarchies and inequalities. As this example suggests, health an\ thropology does not provide simple answers to complex problems; rather it provides \ adequate understandings for the design of effective interventions. This aspect of the health anthropology approach can also be seen in its work on a chronic disease like type 2 diabetes mellitus. The word diabetes co\ mes from Greek and in its original form meant “to run through.” The term re\ flects the ancient Greek view that diabetes causes food to rush through the body instead of feeding it, leading the body ultimately to melt down into urine. Today, \ biomed- icine understands diabetes as a breakdown in the body’s capacity to p\ roduce or respond to the hormone known as insulin, producing an abnormal metabolis\ m of carbohydrates and elevated levels of glucose in the blood and urine. \ In recent decades, diabetes has become a global disease that causes suffering, dis\ ability, morbidity, and mortality worldwide, especially in disadvantaged populations.

This development “reflects the evolving global reach of capitalism \ and colonial- ism, which precipitated increased access to commodity foods, decreased r\ eliance on local food sources, and reduced physical activity” (Rock 2005:474\ ). Anthropologists, in particular, have been involved in the study of diabe\ tes in indigenous populations such as American Indians, who often are said to be genet- ically vulnerable to this debilitating condition. Based on ethnographic \ research, health anthropologists have stressed that the high incidence of diabetes\ in indige- nous populations cannot be explained by a case of bad genes. Diabetes appears to be a relatively new health threat to indigenous peoples, the symptoms of\ which do not show up in older accounts, historical records, or people’s memories of prior generations. Rather, diabetes is a disease with social origins and refl\ ects the biolog- ical consequences of intensely adverse structural factors such as povert\ y, discrimi- nation, loss, trauma, and social stress, common threats to indigenous po\ pulations around the world (Ferreira and Lang 2006, Smith-Morris 2006). What Health Anthropologists Do 53 The Health Risks and Benefits of Kissing From a public health standpoint, is kiss- ing risky? If so, what are the known health risks of kissing? Conversely, are there health benefits of kissing? These questions have received increasing attention in public health since the early 1950s when a bacteriologist reported that up to 250 colonies of bacteria can be transmitted during a single passion - ate kiss (fewer if one of the participants is wearing lipstick). To reach this con- clusion, he recruited a sample of adults and adolescents to kiss a sterile glass slide or agar plate for various periods of time. Fortunately, this research found that the vast majority (95 percent) of kiss-transferred microbes are not patho- genic. Since then, of course, HIV/AIDS became a global pandemic and con- cerns about kissing as a route of lethal viral or other microbial transmission have become widespread. In their studies var - ious social scientists have encountered popular uncertainty about kissing as a risk behavior. In one study, for example, researchers conducted semistructured qualitative interviews with thirty-three HIV-infected parents and their children to investigate fears about HIV transmis- sion. They found that many of these fam- ilies reported transmission fears, includ- ing specific trepidation related to blood contact, contact with bathroom items, food sharing, and kissing/hugging. Many of these fears, including those viewing kissing as an HIV risk, are based on mis- conceptions about modes of HIV trans- mission. While kissing is not a very likely route of HIV infection (because HIV can- not survive in saliva), kissing can be a health risk. In fact, an array of infectious diseases can be transmitted through this form of human intimacy, including strep throat, infectious mononucleo- sis (known colloquially as “kissing dis- ease”), Herpes Simplex Virus-2, Hepatitis B, syphilis, scabies (a contagious skin disease caused by a mite), warts, and meningococcal disease (inflammation of the membranes that cover the brain and spinal cord). College freshmen, for exam- ple, especially those who live in dormito- ries, have been found to be at increased risk for bacterial meningococcal disease compared with age mates who are not attending college or living in a dorm set- ting. Moreover, research in Britain found that people involved in intimate kissing with multiple concurrent partners face a risk four times greater of developing meningitis than those not engaged in this behavior. Sexually transmitted diseases such as syphilis also can be transmitted through kissing if syphilis sores are pres- ent in the mouth or lips of one of the par - ticipants. In addition to various diseases, several studies have found that food allergens can be transmitted through kissing. For example, there is a case of a severe anaphylactic reaction in a young woman with shellfish allergies after kiss- ing her boyfriend (who had just eaten several shrimp; Steensma 2003). On the plus side, research shows that there are several notable health benefits linked to kissing, including the fact that kissing, particularly passionate kissing, lowers cortisol levels, an objective sign of stress reduction. Moreover, kissing can improve self-esteem and feelings of being appre- ciated. Further, kissing helps stabilize cardiovascular activity and reduce blood pressure and cholesterol. 54 Chapter 2 Further, health anthropology research in South Africa found that diabete\ s is linked to and adversely interacts with depression, and both are conne\ cted, in turn, to the role of gendered street violence and structural violence\ in creating everyday fear and chronic distress (Mendenhall 2015). Diabetes, in other words, does not develop into epidemic proportions independent o\ f other diseases or taxing social and economic conditions associated often\ with social inequality. As diabetes has gained global recognition as a disease under the global \ influ- ence of biomedicine, researchers have found that it is being used at the popular level as an idiom of distress for talking about suffering and upsetting \ experience as a bodily condition in a culturally meaningful way (Mendenhall et \ al. 2010).

This insight suggests the importance of investigating the relationship b\ etween experienced suffering and distress and the onset of chronic, noncommunic\ able diseases like diabetes. Research Methods Multimethod Research When conducting a study, a health anthropologist or a team of collaborat\ ing researchers generally combines a number of specific methods. This “\ mixed-method approach” often includes direct observation and detailed recording of\ behaviors and events witnessed in the field, as seen earlier in this chapter in \ Brodwin’s (1996) records of folk treatment observations in Haiti. In addition, health ant\ hropolo- gists generally conduct casual interviews with people as they are going \ about their everyday activities, which Pearl Katz (1999) did as she followed surge\ ons around the hospital she studied. Another method frequently used by health anthr\ o- pologists is in-depth interviewing, such as the detailed interviews cond\ ucted by Bluebond-Langner (1996) in her study of cystic fibrosis. To gain a w\ ider contextual framework for understanding what they find in the field, health anth\ ropologists rou- tinely review historic documents or other existing records, such as Harp\ er’s (2002) examination of the historical and economic literature on Madagascar. Health anthropologists also use ethnosemantic elicitation, as well as a set of specialized systematic cultural assessment techniques, such as free list\ s, pile sorts, and Q-sorts, that allow researchers to glimpse how study participants think about and order the components of their world. Pamela Erickson and her colleag\ ues, for example, used free lists and pile sorts, among other techniques, to \ study sexual health and decision making among inner-city African American and Puerto \ Rican young adults (M. Singer et  al. 2006). In this study, called Project PHRESH, eighteen-to-twenty-four-year-olds were recruited through street outreach\ in Hartford, Connecticut, and Philadelphia, Pennsylvania. In small-group settings, they were first asked to list all the kinds of sexual practices that t\ hey knew. Later, in one-on-one sessions, other participants from the same age and \ ethnic groups were asked to sort cards that were printed with descriptions of s\ exual behav- iors that were listed by at least three of the small groups into piles r\ anging from least to most risky for HIV transmission. Participants were then requested to \ explain why they put cards together in the same pile. Using a special set of compute\ r programs What Health Anthropologists Do 55 called Anthropac, the team was able to prepare a scatter plot of the ove\ rall pattern in the sorted cards, based on an assessment of which cards people tended to\ put in the same pile or keep apart in different piles, across all the participants \ in the study. This approach allowed Erickson and coworkers to see underlying cultural assoc\ iations that shape sexual and romantic relations in their study population. Other tec\ hniques com- monly used by health anthropologists include life history interviews, fo\ cus groups, consensus analysis, and diary keeping. One of the concerns of projects like PHRESH is the recruitment of a samp\ le of individuals who represent a larger population when all of the feature\ s (e.g., overall size, makeup of subgroups) of the larger target population are \ not fully known (and hence the recruitment of a statistically representative samp\ le is not possible). One approach that allows the researcher to combine location and time factors to obtain a large, diverse, and reasonably representative sample\ is known as venue-based sampling (VBS). The keys to the VBS approach are (1) \ rigorous exploration of possible recruitment sites (i.e., venues) where members\ of the tar- get population can be found (e.g., a study of street commercial sex wor\ kers might attempt to identify “stroll” sites where commercial sex workers engage custom- ers); (2) focused observation over a period of time at all identified sites to roughly determine the number of individuals from the target group that are found\ at each site; (3) random selection of venues at selected intervals from the li\ st of identified venues; (4) recruitment of individuals at randomly selected venues combined with observation of the number of members of the target group present during \ the time/date of the recruitment; (5) calculation of the relationship of t\ he number of individuals selected from those available at the site during the recr\ uitment epi- sode; and (6) data collection (e.g., through survey, structured inter\ view, in-depth interview) of recruited individuals. As this description suggests, VBS \ combines qualitative and quantitative strategies to provide researchers with confi\ dence that the individuals they collected data from do not represent a skewed sample that differs in significant ways from the larger population of interest.

Examining Lives The life history interview is used to record the life story of an indivi\ dual, with a strong emphasis on the meaning of life events for the person being inter\ viewed.

James Quesada (1998), for example, used this technique to explore the \ effects of war, endemic poverty, political instability, and social despair on Danie\ l, a gangly ten-year-old boy from the central highlands of Nicaragua. Quesada got to\ know Daniel and his mother while studying health and well-being in the afterm\ ath of war in the Nicaraguan town of Matagalpa. Reflecting the growing int\ erest of health anthropology in the health and social effects of war, aggressi\ on, and interpersonal violence, Quesada analyzed Daniel’s life story as an embodiment of the pain and suffering shared by many Nicaraguan children as a result of the U.S.-supported Contra War that had been fought in the area. Daniel succinctly and coolly summarized his grim life experience one day when he told Ques\ ada (1998:60) that sometimes he felt like dying: “Look at me, I’m all bones anyway.

I’m already dying. I’m too small and I have stopped growing and I \ am another 56 Chapter 2 mouth to feed. My mother can’t keep taking care of my brothers and me\ , and I can’t keep taking care of her. I can’t do anything.” Through this single life history, Quesada gained a far deeper understanding of the embodied exper\ ience of war, its profound health costs, the jagged social disruption it bring\ s, and the abject poverty it often produces. Because of Quesada’s intervention, \ Daniel did not die, but there are few Jim Quesadas and many Daniels in the world. In another health anthropology study, Merrill Singer and Rebecca Allen (2017) used a life history approach to address a fundamental que\ stion in contemporary health care: how do we understand and respond to the pressing health problems of society? The conventional biomedical respons\ e to this question involves description of a type of care that is based on\ care- ful clinical assessment of the immediate health factors presented by eac\ h individual patient and the provision of science-based medical treatment drawn from an arsenal of pharmaceutical, surgical, and other established\ and approved biomedical strategies. In subtle tension with this dominant\ clinical model of medicine, the approach known as social medicine places an equal level of focus on the social conditions and structural inequali\ ties that produce and worsen health problems, including social stigmatization\ , adverse physical factors in built social environments (e.g., overcrowdi\ ng, impoverished neighborhoods, and inadequate diets), structural violence (like entrenched institutional racism), and social injustice. These so\ cial fac- tors contribute to a biology of inequality, powered by the ways social d\ is- parity and deprivation get “under the skin” and are inscribed by d\ isease on body systems. From a social medicine perspective, the fundamental under- lying cause of disparities in health are social and economic inequalitie\ s that either produce illness directly or foster unhealthy behaviors that lead to poor health. While there are various personal accounts of the experience of becoming or working as a conventional physician, prospective medical students have few alternative role models of doctors who are not narrowly focused on traditional individual patient/disease-focused approaches to medical practice. Based on extensive life-history interviews over severa\ l months with a social medicine doctor, Singer and Allen present an alter- native model of biomedical practice within the context of the existing structure of twenty-first-century medicine and in light of the consequen\ tial current unequal distribution of health, living and working conditions, a\ nd medical access. The type of social medicine practiced by this physician, which is informed by a keen awareness of the social origins of health an\ d well-being, reflects many of the life experiences he had growing up and \ the identifiable influences of various friends, family members, and mentors as well as his often troubled experiences with powerful medical institution\ s.

Focus Group Interviews Originally developed by social scientists, focus groups came to be a favored tech- nique of market researchers concerned with assessing the appeal of new products among consumers. In more recent years, anthropologists and other social scientists have readopted focus groups and used them to study many issues, including health. What Health Anthropologists Do 57 Focus groups entail bringing together a group of people and stimulating them to engage in conversations about issues of research and community interest. With this goal in mind, for example, researchers investigating a topic of concern among many Native Americans (Bletzer et al. 2011), alcohol consumption, organized focus groups with members of five tribes from southwest, northwest, and northern plains to discuss this issue. They then used the performance of humor as a stylistic feature of the conversations to explore aspects of adolescent and adult drinking with the insight that how social groups create and use humor is a serious issue for cultural analysis. The researchers found that the most common forms of humor in the con- versations were parody, hyperbole, and word play and that all of these contributed to the ability of the group to discuss a highly sensitive topic. Interpretation of focus group data requires the systematic review of conversational transcripts to identify themes that can be developed and configured, in collaboration with community members, into effective program initiatives. In this instance, appropriate use of humor was found to be an important entrée into collaborative exchange, a lesson for culturally sensitive inter vention. Discovering behavioral practices like this allows health anthropologists\ to design health-related interventions that are grounded in actual beliefs \ and behaviors.

Considering Consensus The term consensus analysis refers to a quantitative procedure used to determine the modal (i.e., most frequent) answers provided by a group to a set of qu\ estions about a particular topic (e.g., “what is a cold?”). Use of consensus ana\ lysis allows researchers to determine the degree of cultural agreement in a group or between subg\ roups of a larger population. For example, asthma beliefs and practices have been f\ ound to vary among ethnic groups. One important variation related to ethnicity is the different descriptors used to express an asthma attack. These descriptions can be \ both physical and psychological in nature. In a multicity cross-cultural comparison of\ four different Latino groups in the United States, Mexico, and Guatemala, health anthro\ pology researchers found broad agreement about the major respiratory signs of a\ sthma, including wheezing, cough, chest noise, and fast or difficult breathin\ g (Pachter et al.

2002). Particular to Puerto Ricans in the Hartford, Connecticut, sample\ , however, was reference to symptoms such as chest pain; decreased activity; increa\ sed blood pressure; chest congestion; fast heartbeat; red, tired, or dark eyes; and difficulty breathing or talking to describe asthma attacks. Because these latter sy\ mptoms were peculiar to one group, they cannot be considered part of a pan-Lati\ no cultural complex. Rather, they are core elements of only a Puerto Rican cultural \ conception of asthma. Failure to understand this kind of information can lead to pu\ blic health efforts that are overly generalized and thus fail to be effective with s\ pecific popu- lations, such as Spanish-language prevention materials that assume that \ the term “asthma” means the same thing to all Latinos.

Doing Diaries Diaries commonly are thought of as very personal records of one’s tho\ ughts, feel- ings, experiences, and relationships, but they have been drafted into th\ e study of 58 Chapter 2 health as well. Researchers studying issues such as drinking behavior, f\ ood intake, and sexual risk have employed diaries as a means of getting insider desc\ riptions of behaviors and experiences as soon after they occur as possible (when me\ mories are at their best). In a study of access to sterile syringes, for examp\ le, a team of health anthropologists, epidemiologists, and other researchers recruited a small sample of active illicit-drug injectors in three cities in New England t\ o record their acquisition, use, and discard of syringes in a daily diary. For example, one of the participants in the study recorded the following information in h\ is diary: [Thursday] 4-13-00 Went to cop [acquire drugs] last night, nobody was ar\ ound.

So we went all over and found some [drugs] finally. Me and John used tha\ t one needle I have. It’s really messed up. But after 20 minutes of trying \ he shot me with 3 bags [injected me with the drugs from three small plastic bags]. \ He then used my works [syringe]. He didn’t clean them or anything. My works a\ re bad.

The tip is all bent.

Fri. April 14th. The works wouldn’t draw up the dope so we were going to put some cream on the black tip [the syringe plunger] so it wouldn’t jam up and [would] slide easier. We continued to have the problem of the works \ not drawing up. They’d start sucking up the dope then would stop. Finally\ it sucked everything from the spoon and he hit [injected] me . . . the works are in bad shape. So it takes him longer to get it in the vain [vein]. But he final\ ly did then we shared spoon and cotton [to filter the drug mixture] and works and he\ did himself next which took a while too because the shape of the needle. It has a burr in it. But we did it.

Through accounts of this sort, the study (Stopka et al. 2004) found that drug users’ diaries elucidated useful information on (1) daily patterns \ of injection drug use, (2) the social contexts of high-risk events, (3) HIV and hepati\ tis risk related to the street life cycle of a syringe, and (4) emotional correlates of dr\ ug use. Further- more, the study discovered an unexpected intervention effect that keepin\ g a diary may have in the lives of drug users: a number of the individuals who kep\ t diaries approached the researchers seeking help. Being pushed into paying closer\ attention to the impact of drugs and the frequency of risk in their lives, they de\ cided to get into drug treatment. Assistance into treatment was readily provided. As \ this exam- ple shows, health anthropology research itself can offer a form of inter\ vention or serve as a model for new intervention approaches in public health. Quantitative Methods In addition to these qualitative research strategies, health anthropologists use various quantitative techniques, such as the sur veys Kendall (1998) used to assess people’s beliefs about dengue in Honduras, described in chapter 1. Qu\ alitative methods can be used, in fact, to improve the quality of quantitative data. In a project focused on the traumas endured by Cambodian refugees in the United States (Hinton et  al. 2015), researchers began by developing an understanding of somatic symptoms and culturally meaningful syndromes. This was done using qualitative inter views with Cambodian patients at a clinic, as well as through con- versations with Cambodian monks, traditional healers, and community lead\ ers. What Health Anthropologists Do 59 Based on the information that was collected, the ethnopsychological condition known as kut caraeun, which translates into “thinking a lot” (TAL) or “thinking too much,” was identified as an important idiom of distress (a concept discussed in chapter 1) among Cambodian refugees. Suffering from TAL involves rumination about unpleasant topics, such as enduring a loss, suffering a setback or failure, or struggling with a current life concern, to the point of experienced distress. Symp- toms of this condition include fear and anxiety, agitated irritability, depression, shortness of breath, insomnia, heart palpitations, neck soreness, and dizziness. As part of a broader mental health assessment with two hundred treat- ment-seeking adult Cambodians in a psychiatric clinic in Massachusetts, \ researchers administered several TAL instruments, including a culturally salient che\ cklist of expe- rienced TAL symptoms and a questionnaire that measured the severity of TAL and of TAL-induced distress. Based on the findings, the researchers argue \ that explo- ration of this idiom of distress provides important clinical insight int\ o local social concerns, the experience of trauma, and Cambodian ideas of ethnopsycholo\ gy. This type of information, they maintain, is critical for the evaluation of ps\ ychological distress and the development of contextually sensitive interventions.

Broader Collaboration Health anthropologists now collaborate with a broad range of other types\ of researchers. For example, a number of health anthropologists work with l\ ab- oratory scientists and collect biological specimens, such as the urine s\ amples described in chapter 1 that were collected by Thomas Arcury and coworkers (2005) among farmworkers to test for pesticide exposure. Multidiscipli\ nary col- laboration of this sort is now quite common in health anthropology. As the global health impacts of climate change have become increasingly \ clear (Baer and Singer 2014), health anthropologists have begun to col\ laborate with climate scientists, health-care professionals, community activists,\ and other concerned individuals. Some of this collaboration has developed through \ anthro- pologists becoming involved in grassroots climate action groups and the \ larger climate social movement that promotes social, economic, and technological changes designed to mitigate climate change and its damaging impacts. No\ tably, one of the cofounders and cochairs of the 2017 March for Science—organized in protest of the Donald Trump administration’s attacks on science, i\ ncluding climate science—was anthropologist Valorie Aquino. Interdisciplinary \ research on climate change and health is another way health anthropologists have partic- ipated in collaborative efforts in climate change mitigation.

Health Anthropology in Use Mobilizing Research Findings Beyond research, health anthropologists commonly are concerned with appl\ ica- tion, that is, with the practical use of their research-gained knowledge\ and expe- rience-gained skills. Application in health anthropology takes many form\ s. Health anthropologists, for example, have carried out research on the lived exp\ eriences of women to help reduce the barriers they face in accessing reproductive he\ alth care. 60 Chapter 2 This can lead to meaningful policy or programmatic changes that improve \ access to needed services (e.g., Ostrach and Matthews 2015). Ethnographic res\ earch has shown that in some settings access to health services is encumbered by s\ treet-level bureaucrats, such as security guards and nurses, or by strict bureaucrat\ ic adherence to official procedure. These barriers can override the clinical needs \ of patients in ways that actively harm their health. To overcome such barriers faced by indi\ genous Maya patients in rural Guatemala, Anita Chary and colleagues (2016) worked with Wuqu’ Kawoqm, the Maya Health Alliance, a nongovernmental organization in Guat\ emala, to develop and implement a patient accompaniment program. This intervent\ ion helps Maya patients with limited Spanish language abilities and low lite\ racy to suc- cessfully navigate hospital environments and gain access to needed care.\ In a very dif- ferent type of applied project, researchers worked with local, small-scale gold mining communities in Peru to develop safe technologies for gold extraction (B\ audin et al.

2016). This is of critical health importance because mercury has long b\ een used by gold miners because it can be mixed with gold-containing rocks to form a\ n amal- gam, which, when heated (and the mercury vaporized) releases the desir\ ed gold.

But mercury vapor is highly toxic to all body systems at even minute lev\ els of expo- sure. To ensure that the new, safe technologies would be acceptable to t\ he miners, the researchers worked closely with them at all stages of design. Miners tested and provided feedback on the various extraction prototypes they were shown a\ nd were pleased with the final models. In this instance, a participatory appli\ ed approach was used to prevent health problems and diminish environmental pollution. Applied health anthropologists are also involved in the direct delivery \ of health care to communities in need. An example, from Haiti is the collaboration\ between HOPE (Health Opportunities for People Everywhere), an international he\ alth orga- nization that provides humanitarian assistance, and Koodinasyon Gwoupman\ Pey- isan Borgne, a Haitian peasant community development organization (Mazz\ eo et al.

2013). Applied anthropologists working with HOPE observed firsthand t\ he positive transformations achieved through community-based peasant development act\ ivities.

Their research helped to guide the work of HOPE with local partners to i\ mplement a range of projects, including health-care and sanitation interventions.\ These were of vital importance because a deadly cholera epidemic broke out in Haiti\ in 2010.

The extensive, capillary-like social network developed by Koodinasyon Gw\ oupman Peyisan Borgne served as a model for the mobilization of volunteers in t\ he fight against the cholera epidemic. Recognizing the importance of social networks in addressing health issue\ s has been an integral component of the approach of many applied health anthro\ pol- ogists. The value of a medical health anthropological focus on social ne\ tworks in the AIDS pandemic (as opposed to one-on-one prevention education models\ that focus on individuals) was demonstrated in the work of Robert Thornton (\ 2008) in sub-Saharan Africa. Thornton was particularly focused on sexual networks, which he noted are invisible even to the people who participate in them (in t\ hat people know who they have had sex with but not all of the people their partners\ have had sex with, and certainly not all of the people their partners’ partner\ s have had sex with). Thus, he referred to sexual networks as unimagined communities. Yet, in sub-Saharan Africa, where sex is the dominant route of HIV transmission,\ sexual networks are absolutely critical to whom, to where, and to how quickly H\ IV spreads. What Health Anthropologists Do 61 Indeed, it became Thornton’s view that it was precisely because they \ focused on individuals and not on sexual networks that many AIDS education campaign\ s had little effect in slowing the epidemic in many places. The AIDS preventio\ n effort in Uganda, where Thornton did his research, was comparatively successful, b\ y contrast, because the population is largely rural and dispersed, socially segmente\ d by class, ethnicity, and religion, and not particularly mobile. Moreover, the coun\ try was hit early and hard by AIDS. Noted Thornton (2008:231): “All of these fa\ ctors had the effect of eliminating links between clusters of previously sexually link\ ed people, and the whole [sexual] network collapsed. HIV was no longer transmitted effi\ ciently throughout the network, and HIV prevalence fell dramatically.” Based \ on his analy- sis of the AIDS epidemic in Uganda and South Africa, and the behaviors t\ hat occur in sexual networks that promote the spread of HIV, Thornton recommended \ that effective HIV/AIDS prevention should (1) encourage people to limit the\ mselves to one sexual partner at a time (as having concurrent sexual partners with\ people who also have multiple concurrent sexual partners facilitates the rapid spre\ ad of the epi- demic), (2) promote the idea that at the end of a sexual relationship\ people should refrain from having new sexual partners for at least one month (because people are most likely to infect others in the first month or so after they becom\ e infected), and (3) uphold the idea that people should avoid sex when traveling away f\ rom home (which would slow the ability of the virus to jump to new areas). As these examples show (and a very long list of additional examples cou\ ld be cited), health anthropology is not isolated in the ivory tower of ac\ ademia.

It is being used daily in numerous places around the world, from the mos\ t remote villages to the largest and most technologically advanced megalop\ o- lises, to address health-related problems of many kinds, such as community nutrition education (figure 2.1). Very likely, there is a health anthropologist working in the city or town where you live (or at least nearby), attem\ pting to use anthropological skills to address real-world health problems. Finall\ y, not all of applied health anthropology is a post hoc product of a research p\ roject.

Health anthropologists also design and oversee intervention programs, ev\ aluate the effectiveness of programs, and are involved in helping to establish \ and use ethical standards in health-care decision making.

The Health Anthropology Crystal Ball What is the future of health anthropology? Where is the field going? H\ ow might it change over the coming decades? As jocosely summarized by Danish physici\ st Niels Bohr: “Prediction is very difficult, especially if it’s about th\ e future.” One thing, however, is clear: as Nancy Scheper-Hughes and Margaret Lock (1987) ar\ gued some time ago, it is a fallacy to believe we will discover a narrow biotechno\ logical salvation or magical medical bullet to solve all of the many old as well as emergent health and social problems faced by humankind. Human health problems reflect huma\ n social life and social interactions with the environment, and thus addressing h\ ealth issues means knowing about the details of the social structural, environmental,\ and cultural aspects of the human condition. Herein lies an ongoing role for health a\ nthropology.

Without question, health anthropology also will be shaped by the social \ and physical worlds of the future. That future, as Yogi Berra once quipped, “ain’t what it used 62 Chapter 2 to be.” This is particularly true with reference to health. One of th\ e reasons is the impact of ecobiosocial changes taking place on planet earth. A second reason has to do with the configuration of the social worlds we are constructing. As a result of these changes, in addition to many of the current areas of focus, health anthr\ opologists of tomorrow will be progressively more concerned with issues such as the\ following factors. First is the far-reaching and increasingly faster pace of globalism, whi\ ch facil- itates the global spread of diseases around the world (e.g., diabetes). Globalism also contributes to the restructuring of local social contexts and ways \ of life in ways that create or enhance health vulnerabilities. One critical factor \ in this regard is what have been termed “killer commodities,” that is, global pro\ ducts distrib- uted around the world for a profit that cause harm to c