Brown Ch 12 (Foster) - s12 Disease E tiologies in N...

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Unformatted text preview: s12 Disease E tiologies in N art-Western Medical Systems George M. Foster lfe'oery culture in the world has a medical system, or, more properly, an ethnomedical system, then how is it possible to talk about this great variation? How is it possible to com- pare medical systems that are based on completely difi‘erent ideas of what causes illness—Thom spirits to germs? The first thing that social scientists do when faced with such a problem is to survey the range of variation and then con- struct a system of categorization, also called a typology. This is a comparative method in which like is grouped with like. The next step is to define these groups with descriptive labels using what the famous sociologist Max Weber called "idealgypesf In this classic article, George Foster surveys the range of variation in medical systems and focuses on an essential aspect of such systems: the etiology or theory of disease cau- sation. This is a good place to start, because medical systems must have three basic components: a theory of etiology, a system of diagnosis, and techniques of appropriate therapy. Theories of causation are actually cognitive blueprints, something that medical anthropologists often refer to as ex- planatory models. The distinction between naturalistic and personalistic ethnomedical systems is quite useful. Naturalistic systems tend to have etiologic explanations that are restricted to the disease symptomatology and a single level of causality. In contrast, personalistic explanations extend to the domains of social relations—with living people, ancestors, and other spiritual entities. Naturalistic cures tend to be oriented to- ward the physical body; personalistic cures must not only deal with immediate causes for an illness (like witchcraft) but also the underlying social nfis that have provoked the witchcrafi. One of the most interesting aspects of this distinction is that personalistic and naturalistic systems have completely difl‘erent attitudes about the sharing of medical knowledge. In a personalistic system, a shaman gains prestige as a healer in part because he jealously guards his personal eth- nomedical lowwledge. In a naturalistic system, a healer gains prestige by producing and giving away medical knowledge—by teaching it to others. The more open infor- mation system has adaptive advantages because therapies can be openly compared and evaluated. Naturalistic systems are associated with the great traditions of complex civiliza— tions; medical knowledge becomes codified and taught as a profession. Notice that the author doesn’t clearly come out and say that scientific biomdiclne is a naturalistic ethnornedical system But a careful reading will reveal that biomedicine has more of the attributes of the naturalistic ideal type. Also notice that these ideal types do not really work as a clean and neat categorization scheme. There are two reasons for this: First, many ethnomedical systems have attributes of both naturalistic and personalistic etiologies (the Navajo median! system is an example ofone that doesn’tfit the ty- pology); second, many societies have multiple medical sys— tems operating simultaneously or medical pluralism. As you read this selection, consider these questions: I Why is it that the author believes that personalistic sys- tems are evolutionarily older than naturalistic eth— . nomedical systems? I Are personalistic ethnomedital systems kinder to the oictimofthediseasebecausetheydonotblameaperson for getting sick? Or is a person really responsible fin keeping peaceable social relations to prevent spiritual ‘ attacks? - I What is the logical connection between etiologic theo- ries and therapeutic practices? Impressive in ethnographic accounts of non-Western medicine is the tendency of authors to generalize from the particulars of the system(s) withjn which they have worked. Subconsciously, at least, anthropologists filter the data of all exotic systems through the lens of belief and practice of the people they know best. Whether it be causality, diagnosis, the nature and role of the curm- or the perception of illness within the wider supemai' ural and social universe, general statements seen! - strongly influenced by the writers’ personal eXpefl' ences. Click, for example, in one of the most interesting of recent general essays, notes that in many culture! rer- I , yon and medical practices are almost inseparable, . , I-. he adds that ”We must think about how and where ." medicine“ fits into 'religion’. . . . In an ethnography of _, religious system, where does the description of the J -, ,_... 'cal system belong; and how does it relate to the ."'... ' der?" {Glick 1967133). ' Yet in many medical systems, as, for example, .. .. - characterizing mestizo villagers and urbanites in .~ 3 .-- ‘ America, medicine would have the most mini- ma] role in an ethnography of religious beliefs and ‘ ' practices. Illness and curing are dealt with largely in , .menreligious terms. In Tzintzuntzan, for example, in ' ' many hours of recording ideas about origins and cures . stillness, not Once has religion been mentioned—even though most villagers, if asked, would certainly agree that illness ultimately comes from God. The ethnologist analyzing medical beliefs and practices in an African community can scarcely avoid dealing with witchcraft, oracles, magic, divining, ~and propitiation, all of which are categories of only modest concern to th ' student of Indian Ayurvedic medicine. In short, there has been all too little dialogue between anthropologists who have studied dramatically differ- ent non-Western medical systems. So striking is the parochialism at times that one is tempted to agree with the medical sociologist Freidson who notes the existence of a "very large body of sociological and an- thropological infonnation” about popular knowledge of and attitudes toward health and disease, but finds most of it to be ”grossly descriptive.” "Aside from cultural designations like Mexican, Subanun, and Mashona,” he writes, “there is no method by which the material is ordered save for focusing on knowl- _, edge about particular illnesses. Such studies are essen— ' tially catalogues, often without a classified index” (Freidson 1970:10). Yet if we can successfully classify kinship, political and economic systems, and witchcraft and sorcery be- liefs, and find the significant behavioral correlates as- sociated with each, then certamly we can do the same with medical systems. We are, after all, dealing with ' - limited possibilities in each of these cases. In this paper I am concerned with the cross-cultural pattern— ~ ing that underlies non—Western medical systems, and with identifying and explicating the primary indepen— dent variable—disease etiology—around which orbit Such dependent variables as types of curers, the na- ture of diagnosis, the roles of religion and magic, and the like. This is, then, an essay on comparative eth- l nomedicine, a term Hughes aptly defines as “those be- liefs and practices relating to disease which are the _ products of indigenous cultural development and are - not explicitly derived from the conceptual framework of modern medicine" (Hughes 1968:99). ' f"‘-r1v- . -'.'].F."H" Disease Etiologies in Non-Western Medical Systems 111 THE PROBLEMS OF TERMINOLOGY Throughout most of anthropology's brief history eth» nologists have labeled the institutions of the peoples they have studied as “primitive,” ”peasant," or "folk,” depending on the basic societal type concerned. Until relatively recently we investigated primitive reiigion, primitive economics, primitive art—and, of course, primitive medicine. The seminal writings of the ethnologist-physician Ackerknecht during the 19405 display no uncertainty as to what interested him: it was ”primitive medicine,” a pair of words that ap- peared in the title of nearly every article he published (Ackerknecht 197]). Caudill, too, in the first survey of the new field of medical anthropology spoke unashamedly of "primitive medicine” (Caudjll 1953). When, following World War II, studies of peasant communities became fashionable, these peoples were described as possessing a ”folk culture." Not surpris- ingly their medical beliefs and practices were labeled “folk medicine,” a frequent source of confusion since the popular medicine of technologically complex soci- eties also often was, and is, so described. In recent years, however, this traditional terminol— ogy has come to embarrass us. In a rapidly changing world, where yesterday’s nonliterate villagers may be today's cabinet ministers in newly independent countries, the word “primitive”—initially a polite euphemism for ”savage”-—is increasingly outmoded. Ackerknecht himself reCOgnizas this change, for in the 1971 collection of his classic essays most titles have been edited to eliminate the word ”primitive.” ”Peasant” and "folk" are less sensitive words, but they too are being replaced by "rural," ”agrarian,” or some thing of the kind. The extent to which we have been troubled by terminology is illustrated by the circum- locutions and quotation marks found in the major re view articles of recent years: “popular health culture,” "indigenous or folk medical roles," ”nonscientific health practices,” "native conceptual traditions ab0ut illness,” ”culture specific illness," “the vocabulary of Western scientific medicine,” ”indigenous medical sys— tems,” and the like (e.g., Polgar 1962; Scotch 1963; Fabrega 1972; Lieban 1973). ETIOLOGY: THE INDEPENDENT VARIABLE Yet the greatest shortcoming of our traditional medical terminology—at least within the profession itself—is not that it may denigrate non-Western people, but 112 Belief and Ethnornedical Systems rather that, by focusing on societal types it has blinded us to the basic characteristics of the medical systems themselves. There is more than a grain of truth in Freidson’s cements, for many accounts are ”grossly descriptive,” with lists of illnesses and treatments tak- ing precedence over interpretation and synthesis. 50 where do we start to rectify the situation? Click (1967:36), I believe, gives us the critical lead when he writes that ”the most important fact about an illness in most medical systems is not the underlying pathologi— cal process'but the underlying cause. This is such a cen- tral consideration that most diagnoses prove to be statements about causation, and most treatments, re- sponses directed against particular causal agents” (emphasis added). A casual survey of the ethnomedical literature tends to confirm Glick’s statement. In account after ac- count we find that the kinds of curers, the mode of di- agnosis, curing techniques, preventive acts, and the relationship of all these variables to the wider society of which they are a part, derive from beliefs about ill- ness causality. It is not going too far to say that, if we are givén a clear description of what a people believe to be the causes of illness, we can in broad outline fill in the other elements in that medical system. It there- fore logically follows that the first task of the anthro- pologist concerned with medical systems is to find the simplest taxonomy for causality beliefs. Two basic principles, which I call personalistic and naturalistic, seem to me to account for most (but not all) of the eti- ologies that diaracterize non-Western medical sys- tems. While the terms refer specifically to causality concepts, I believe they can conveniently be used to speak of entire systems, i.e., not only causes, but all of the associated behaviOr that follows from these views. A personalistic medical system is one in which disease is explained as due to the active, purposeful in- tervention of an agent, who may be human (a witch or sorCerer), nonhuman (a ghost, an ancestor, an evil spirit), or supernatural (a deity or other very powerful being). The sick person literally is a victim, the object of aggression or punishment directed specifically against him, for reasons that concern him alone. Personalistic causality allows little room for accident or chance; in fact, for some peoples the statement is made by anthropologists who have shrdied them that all illness and death are believed to stem from the acts of the agent. Personalistic etiologies are illustrated by beliefs found among the Mano of Liberia, recorded by the physician Harley, who practiced medicine among them for 15 years. “Death is uruiatural,” he writes, "re- sulting from the intrusion of an outside force,” usually directed by some magical means (Harley 19417). Similarly, among the Abron of the Ivory Coast, “People sicken and die because some power, good or evil, has acted against them. . . . Abron disease theory contains a host of agents which may be responsible for a specific condition. . . .These agents cut across the natural and supernatural world. Ordinary people, equipped with the proper technical skills, sorcerers, various supernatural entities, such as ghosts, bush devils, and witches, or the supreme god Nyame, acting alone or through lesser gods, all cause disease” (Alland 1964:714—715). In contrast to personalistic systems, naturalistic systems explain illness in impersonal, systemic terms. Disease is thought to stem, not from the machinations of an angy being, but rather from such natural forces or conditions as cold, heat, winds, dampness, and, above all, by an upset in the balance of the basic body ele- ments. In naturalistic systems, health conforms to an equilibrium model: when the humors, the yin and yang, or the Ayurvedic dosha are in the balance appro- priate to the age and condition of the individual, in his natural and social environment, health results. Causality concepts explain or account for the upsets in this balance that trigger illness. Contemporary naturalistic systems resemble each other in an important historical sense: the bulk of their explanations and practices represent simplified and popularized legacies from the ”great tradition” medi- cine of ancient classical civilizations, particularly those of Greece and Rome, India, and China. Although equi- librium is expressed in many ways in classical ac- counts, contemporary descriptions most frequently deal with the “hot-cold dichotomy” which explains ill- ness as due to excessive heat or cold entering the body. Treatment, logically, attempts to restore the proper bal- ance through ”hot" and "cold" foods and herbs, and other treatments such as poultices that are thought to withdraw excess heat or cold from the body. In suggesting that most non-Western etiologies can be described as personalistic or naturalistic lam. of course, painting with a broad brush. Every anthro~ pologist will immediately think of examples from his research that appear not to conform to this classifica- tion. Most troublesome, at least at first glance, are those illnesses believed caused by emotional distur- bances such as fright, jealousy, envy, shame, anger, 01' grief. Fright, or susfo, widespread in Latin America. can be caused by a ghost, a spirit, or an encounter with the devil; if the agent intended harm to the victim. the etiology is certainly personalistic. But often account" of such encounters suggest chance or accident rather than purposive action. And, when an individual slips beside a stream, and fears he is about to fall into the water and drown, the etiology is certainly naturaliSfl‘i. The Latin American mains, an indisposifion resulting from anger, may reflect a disagreeable inter- -:’ persona-l episode, but it is unlikely that the event was 2- staged by an evil doer to bring illness to a victim. In Mexico and Central America the knee child’s envy '_ and resentment of its new sibling-to—be, still in the , mother's womb, gives rise to chip-ii, the symptoms of _ which are apathy, whining, and a desire to cling to the . mother’s skirt. The foetus can be said, in a narrow - W, to be the cause of the illness, but it is certainly L not an active agent, nor is it blamed for the result. - Since in a majority of emotionally explained illnesses i it is hard to identify purposive action on the part of an agent intent upOn causing sickness, I am inclined to view emotional etiologies as more nearly conforming to the naturalistic than to the personalistic principle. Obviously, a dual taxonomy for phenomena as com- plex as worldwide beliefs about causes of illness leaves many loose ends. But it must be remembered that a taxonomy is not an end in itself, something to be polished and admired; its value lies rather in the understanding of relationships between appar- ently diverse lphenomena that it makes possible. I hope that the following pages will illustrate how the personalistic-naniralistic classification, for all its loose ends, throws into sharp perspective correlations in health institutions and health behavior that tend to be overlooked in descriptive accounts. Before proceeding, a word of caution is necessary: the two etiologies are rarely if ever mutually exclusive as farastheirpresenceorabsenceinaparticularsociety is concerned. Peoples who invoke personalistic causes to explain most illness usually recognize some natural, or chance, causes. And peoples for whom naturalistic causes predominate almost invariably explain some illness as due to witchcraft or the evil eye. But in spite of obvious overlapping, the literature suggests that many, if not most, peoples are committed to one or the other of these explanatory principles to account for a majority of illness. When, for example, we read that in the Venezuelan peasant village of E1 Morro 89% of a sample of reported illnesses are "natural” in origin, whereas only 11% are attributed to magical or super- natural causes (Suarez 1974), it seems reasonable to say that the indigenous causation system of this group is naturalistic and not personalistic. And, in contrast, when We read of the Melanesian Dobuans that all ill- ness and disease are attributed to envy, and that ”Death is caused by witchcraft, sorcery, poisoning, suicide, or actual assault” (Fortune 1932:135, 150), it is clear that personalistic causality predominates. Although in the present context I am not con— tented with problems of evolution, I believe the per- sonalistic etiology is the more ancient of the two. At the dawn of human history it seems highly likely that all illness, as well as other forms of misfortune, was ex- plained in personalistic terms. I see man’s ability to 1‘13 Disease Etiologies in Non-Western Medical Systems depersonalize causality, in all spheres of thought, in- cluding illness, as a major step forward in the evolu- tion of culture. ETIOLOGIES: COMPREHENSIVE AND RESTRICTED We now turn to the principal dependent variables in medical institutions and health behavior that correlate with personalistic and naturalistic etiologies. The first thing we note is that personalistic medical etiologies are parts of more comprehensive, or general, explana- tory systems, while naturalistic etiologies are largely restricted to illness. In other words, in personalistic systems illness is but a specrhl case in the explanation ofull misfortune. Some societies, to quote Horton (1967) have adopted a ”personal idiom" as the basis of their attempt to understand the world, to account for al- most everything that happens in the world, only inci- dentally including illness. In such societies the same deities, ghosts, witches, and sorcerers that send illness may blight crops, cause financial reverses, sour hus- band-wife relationships, and produce all manner of other misfortune. To illustrate, Price-Williams states ”The general feature of illness among the Tiv is that it is interpreted in a framework of witchcraft and malev- olent forces” (1962123) “In common with a great many other people, 'Iiv do not regard 'illness’ or “dis- ease’ as a ...
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