Patterns of Disease and Patterns of Culture

Human reactions to disease also create patterns. Imagine a Peruvian fisherman who ate contaminated shellfish in January 1991, contracted cholera, and died. Individuals in his town gathered to wash the body and to mourn the deceased. They drank and ate together, finding companionship. But some of the participants were exposed to cholera in the shared water. Their travels after the funeral changed the likelihood of exposure for many others, and the number of people they saw and the activities they undertook further influenced the spread of the disease. In April 1991, cholera broke out in mountain villages when recently infected but still asymptomatic workers from the coast traveled home to celebrate Easter. Their behavior as a group created patterns that could not be deduced from the sum of their individual actions. Individual decisions and epidemic patterns are partly separable but clearly linked.

Closely related to the kinds of individual decisions and behavioral patterns we have been talking about, culture also influences human health and the patterning of disease. Our total way of life (work, food, activities), combined with our learned behavior (including knowledge, lies, and misunderstandings), our techniques for adjusting to the environment, and our ways of feeling and believing all influence our susceptibility to illness. Some argue that they become written into our genes, and they certainly become written into our bone structure and musculature. Migrant farm workers, for example, have different diseases than coal miners, and Central American men who wield machetes all day for their whole lives often develop one arm longer than the other.

Bodies and pathogens are determined not just by physical actions but by beliefs about what is important. Beliefs are powerful motivators. The disproportionate mortality among infant girls in some South Asian nations is partly an outcome of cultural preferences for sons over daughters (Sen 1992). In cultures where injections are thought to be stronger than pills, a town might have several specialized injectionists on call to administer to the sick (Reeler 2000). And diagnostic preferences among physicians in different countries are responsible for some of the national differences in rates of depression, low blood pressure, and infant mortality (Payer 1988). Rates of morbidity (sickness) and mortality (death) are determined in part by cultural scripts that specify how, where, and when to behave in certain ways.

The influence of culture can be seen in how people care for symptoms before they receive a diagnosis. Groups vary in their willingness to undertake preventive measures; they vary in how they perceive and classify symptoms. Across the world, people employ diverse markers to decide who will be labeled disease-ridden or contagious; they differentially rank which diseases are seen as important or unimportant. What treatment, if any, sick people choose, whether they take medication, how they manipulate their diseases for other ends, whether therapy succeeds -culture influences diseases through these pathways as well as through the patterned work of nerves, muscles, and bones. Whether one thinks of body disorder as influenced by Chinese energy meridians, Tibetan pulses, Latin American hot/cold states, or immune system function is largely a product of where one is and with whom one interacts. Available healing traditions range from the grand and ancient ones of Chinese acupuncture or Greek humoral pathology of blood and bile to more recent precepts of homeopathy or chiropractic in North America. Biomedicine is one particularly widespread form of therapy in the world today, which bases its treatments on a combination of empirical tests and custom. It is a cultural system like the others, often competing with them, less frequently collaborating.

Yet cultural meanings are also local and contested. This aspect of culture highlights its dynamic, changing quality and gives weight to forces of change and interaction. From this perspective, culture is constantly being transformed. People within groups may be aware of group norms, but those norms themselves change over time, and people choose to reject the norms or manipulate their behavior within them. For example, human beauty standards, and their health-related consequences, change dramatically over time. The corset allowed one set of health problems (muscle atrophy, liver damage) to emerge, whereas a century later breast augmentation caused others (pain, scar tissue, implant rupture). Food preferences, time pressure, and large-scale industrial meal production combine to create a new epidemic of obesity based on "fast food" and sedentism.

Cultural categories not only change through time, but they also can be differentially manipulated by people interacting within a web of relationships embedded in a larger material and social context. In that context, individuals pick and choose different aspects of culture to form their own identities; they manipulate cultural symbols, transform them, and combine them in unexpected ways that can protect health or promote disease. Statements about "culture," whether made by local "natives" or well-intentioned "outsiders," need to be evaluated not only in terms of their content but also in terms of the purposes of those who assert them.

This book describes the connections between patterns of disease and patterns of culture to highlight the creative interdisciplinary ways by which researchers are confronting today's vexing and complex health challenges. By creating conversations across disciplines, students and practicing professionals are better able to collaborate across disciplines, design successful health interventions, and communicate more broadly and clearly with both professional and popular audiences (Dunn 1979). These processes will help develop more appropriate health policies, deepen understandings of disease causation and treatment, and create more effective actions to enhance health and prevent disease.

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