one question – DUE IN 3 HRS!!!!!

This week you are reading about different medical traditions. In what ways does culture influence health and healing beliefs? Please use examples from the course materials.

ATTACHED ARE ARTICLES TO USE TO ANSWER. NO PLAGERISM. DUE WITHIN 3 HOURS PLEASE. ONLY NEED A 5-8 SENTENCE ANSWER WITH CITED SOURCES. 

C O M M E N T A R Y

Ethnography and the Making of Modern Health
Professionals

Vincanne Adams • Sharon R. Kaufman

Published online: 4 May 2011

� Springer Science+Business Media, LLC 2011

…it is particularly incumbent on physicians in this time of instability and
change to concern themselves with medicine in its largest social sense – with

that part of medicine that cannot be construed in terms of laboratory findings

and standard protocols alone. To be a medical citizen is to concern oneself

both with the realm of politics and social justice and with clinical judgment.

—Charles Rosenberg, Our Present Complaint: American Medicine Then
and Now

Charles Rosenberg’s call to arms for the training of health professionals as

optimal medical citizens—concerned with politics, social justice and clinical
judgment—recalls a long history of social science engagement with the socio-

economic and political sources and contexts of medical practice (Rosenberg 2007).

Social scientists equipped with ethnographic and analytical insights have offered

critiques from ‘‘the outside’’ for years, noting how biomedicine engages, knowingly

or not, in iatrogenesis (Illich 1982), capitalist exploitation (Navarro 1976),

domination (Freidson 1970)and reductionism (Gordon 1988), that it disregards

the social conditions of knowledge production (Young 1982) and that it turns life

cycle processes and behaviors into objects requiring medical intervention (Conrad

1992; Zola 1972) for example. The examination of medicine as a social and cultural

system that reproduces problems of social inequality or injustice, rather than

eradicating them, never seems to slow. The route by which this reproduction occurs,

V. Adams (&)
Medical Anthropology, School of Medicine, University of California, San Francisco, San Francisco,

CA, USA

e-mail: AdamsV@dahsm.ucsf.edu

S. R. Kaufman

Medical Anthropology, UCSF Institute for Health and Aging, University of California,

San Francisco, San Francisco, CA, USA

e-mail: Sharon.Kaufman@ucsf.edu

123

Cult Med Psychiatry (2011) 35:313-320

DOI 10.1007/s11013-011-9216-0

more often than not, is through the knowledge, practice and development of health

professionals, but seldom has analytic focus been explicitly on the health

professionals themselves. With this in mind, this fine collection marks a significant

moment in social science analyses of biomedical, and especially clinical, knowledge

and practice by taking as its focus the training of—that is, the production of ethical,

practical and practicing—health professionals. This collection investigates how

some of these previously identified problems persist, creating vexing new ethical

challenges for us all. It offers insights that should be read by all health professionals

in training, and we heartily welcome it.

The articles cover a wide range of contexts and problems—from clinical rounds

in elite medical schools to rural services for dentists in training, from US struggles

with cultural competency to global health struggles with cross-cultural poverty.

Together, they expose the profound influence of contemporary forms of rationality

and ethicality on the restructuring of health care, the shaping of health professional

subjectivity and the goals of medicine. The pathways of training and treatment they

interrogate derive from business models of education and ‘service delivery,’ in

which measurability is the key method and outcome. They question the benefit of

efforts to standardize and quantify health care routines. They expose the hidden

costs of new strategies to encourage empathy, cultural sensitivity, and knowledge/

practice of compassionate expertise. The articles show how efforts to transform

patients, health professionals and health care organizations into more effective

practice machines often fail, sometimes miserably, and in almost all cases arouse a

set of ethical questions about how to get things right. Do medical reforms that insist

on recognizable and quantifiable modules in order to maximize efficiency and

generalizability really make for a better kind of medicine, or even one that is

measurably more efficacious? Do efforts to require cultural competency result in

more culturally appropriate care or do they reproduce cultural stereotypes and

ethnocentrism/racism? Do routines of rural care or service in under-resourced

nations or communities make better doctors and dentists, or do these encounters

reproduce structural problems that reinforce social inequality?

The authors in this collection offer new insights on all of these conundrums and

more. They underscore how market-based tools are affecting ethical sensibilities

and work routines. Students and professionals must learn how to recognize and

manage the new objects of value in the biomedical infrastructure—the ‘‘best

practices,’’ ‘‘cultural competence,’’ and routine practice rituals in which medical

competence is enacted. The main actor in this restructuring is the assemblage of new

pedagogical and health care technologies that permeate health professional

activities today, and these articles document the ways in which those technologies

govern practitioners’ understandings of ethical comportment, appropriate care, what

ails the patient and what can and should be done about it. Those technologies

include, for example, the electronic medical record; computer based teaching tools

of all sorts; the standardized patient; the problem oriented patient presentation;

models of ‘cultural competency training; and routinization of class difference as a

diagnostic tool in poor settings.

This collection draws attention to the linkages of governance which are forged

between infrastructural and bureaucratic demands on the one hand, and what it takes

314 Cult Med Psychiatry (2011) 35:313–320

123

to be a ‘good’ clinical-citizen/practitioner on the other. The explorations demonstrate

the ways in which health professionals come to constitute ‘‘themselves as moral

characters’’ (Brada; Shaw and Armin; Stonington) and as ‘‘ethical clinical-citizens’’

(Rivkin-Fish) while also ‘‘being protocoled into oblivion’’ (Pine) or otherwise

(re)-skilled in today’s market-driven health care delivery system. They show that

many of these training protocols, despite being designed to overcome the problems of

social inequality, actually reinforce social injustices, commodified health care, and a

blaming of the victims of poverty and global inequality. At the same time, these

articles point to the fraught nature of this ratcheting back and forth between a hoped

for, new and improved medicine by way of streamlined, quantifiable training, and the

unintended and undesired outcomes that such reforms produce. They reveal how

difficult it is to become a health professional who is engaged in, as Rosenberg notes,

not only good clinical judgment (based on laboratory tests and standard protocols) but

also in actions to redress the social causes of inequality and injustice that underlie

medicine’s persistent shortcomings and blind spots. By emphasizing the centrality of

structures of power and the social relationships and enactments that render the

consequences of those structures invisible in the formation of health professionals,

this collection serves as a stimulus for further social science explorations of medical

epistemology and the organization of training and care. It suggests that despite all

these years of reform, much of which was inspired by previous critical engagements,

we still have a long way to go.

Holmes, Jenks, and Stonington stress in their introduction that these articles stand

on the shoulders of anthropologists and sociologists who began investigating

biomedicine as a sociocultural system decades ago. Attention to the intellectual

roots of this collection reminds us of some of the enduring thematic concerns for

analysts of biomedical knowledge and practice. The more recent regimes of training

and truth-making that this collection explores illustrate newly powerful dimensions

of the biomedical enterprise that demand social science investigation and critique.

Beginning with her 1957 essay, ‘‘Training for Uncertainty,’’ Renee Fox has

documented over nearly a half century the ways in which uncertainty has affected

the organization of training and the everyday work of medicine, and the ways

uncertainty intersects with physician understandings of treatment, prognosis and

suffering (Fox 1957). Her 1980 article, ‘‘The Evolution of Medical Uncertainty,’’

described how uncertainty at the bedside was heightened by scientific and

technological developments in the 1970s which enabled medical progress in

diagnosis, treatment and prevention at the same time as those developments

increased overall risk awareness (of powerful therapeutic side-effects; of research)

and fostered new (and perhaps unrealistic) expectations about health, longevity and

the elimination of disease. The result, she wrote, is that, ‘‘The development of

scientific medicine, then, has both uncovered and created uncertainties and risks that

were not previously known or experienced’’ (Fox 1980).

When Fox revisits the scope of uncertainty in 2000, she describes its enduring

tenacity and most recent forms—the result of the emergence and re-emergence of

infectious disease, the ascendance of genetic knowledge, therapies, and technol-

ogies, the problems of iatrogenesis and medical error and the constraints of

evidence-based medicine on the hallowed doctor–patient relationship. She notes, for

Cult Med Psychiatry (2011) 35:313–320 315

123

example, that increased diagnostic and treatment capabilities produce prognostic

data and that physicians are under greater pressure than ever before to make clinical

predictions, which they are loathe to make and not trained to deliver. Epistemo-

logical uncertainty, too, runs through medical practice and the medical literature.

The shifting nature of medical knowledge is made more troublesome by the

demands of evidence-based medicine which constantly replaces old truths with new

knowledge and which leads to questions about which evidence is good enough (Fox

2000). Her studies on these topics moved beyond socialization theory to illustrate

how health professional ethical knowledge and practice are organized by the

contours of science and the move towards managed care. Along with others, she

emphasized that bioethics, in its focus on logico-rational principles of analytic

philosophy, ignores the topics of health disparities, unequal power relations and

poverty as ethical problems that are foundational to disease and illness and integral

to medicine (Fox 1990, 2000). Her work drew connections among medical training,

practice and the formation of ‘‘medical citizenship’’ that Rosenberg, in the epigraph

above, later describes and that this collection further explores.

Physician sensibility, scientific and institutional developments and the links

between them are emplaced firmly in the broader realm of the social in the essays

assembled by editors Margaret Lock and Deborah Gordon, in Biomedicine
Examined (1988). That collection was among the earliest to strongly demonstrate
‘‘the social and cultural character of all medical knowledge’’ (p. 7) and the ways in
which medical and scientific practice are inherently social enterprises, interdepen-

dent with society. The volume sought to dismantle the idea that biomedicine, and

the sciences on which it rests, represent an objective and value-free form of

knowledge ‘‘which claim neutrality and universality’’ (p. 19). The essays reveal how

structures of medical practice are socially constructed, how values strongly shape

what physicians do and that disease categories and definitions are not given but

rather are created, represented and understood in institutional, cultural, and

historical contexts. Above all, the volume illustrates that biomedicine is not a

monolithic entity, but rather that it is comprised of specific practices, rituals and

ideologies, all well within the realm of social analysis.

From the 1990s, analyses of the many forms and features of the biomedical

enterprise have stressed its location in political and economic webs of power

relations in which health disparities flourish and social justice languishes. The role

of the ‘technological imperative’ in medicine, central to US medicine from the mid-

twentieth century, has become even more dominant as evidence-based medicine

supports an expansive clinical trials industry and the creation of more therapeutics

for more conditions—but only for those who can gain access to them. The

‘biotechnical embrace’ (Good 2001) is now a world-wide phenomenon, contributing

to new forms of ‘‘ethical self-formation’’ among practitioners (Stonington) and the

development of a dual discernment of appropriate, ethical care depending on

whether one is practicing medicine ‘here’ or ‘there’ (Brada; Rivkin-Fish). Greater

fragmentation in health care delivery, greater emphasis by health care organizations

on models of efficiency for training and practice, the normalization of differential

treatments in affluent and poor settings, and computer-guided diagnosis, treatment,

charting and goal setting all have changed clinical medicine and the ways in which

316 Cult Med Psychiatry (2011) 35:313–320

123

trainees and professionals learn to ‘do’ medicine, to ‘be’ clinicians and to function

within medicine’s highly varied organizational environments (Holmes and Ponte;

Pine; Taylor; Shaw and Armin). These most recent developments are the crux of the

matter in this collection. What these articles show us has unsettling implications for

the future of medicine as a practice in which healing and social justice can thrive.

Recognition is the large, unifying theme that runs through these articles—that is,
what students and professionals are taught to recognize as the skills that constitute

clinical-ethical citizenship in the market-driven, standardized, and high-tech health

care arena today. Each article explores how what many would call ‘‘new and

improved’’ techniques that clinicians and clinicians-in-training learn actually govern

their understandings of patients, treatments, and their own clinical-ethical expec-

tations of caregiving in particular settings. Each portrays specific tools now

considered essential or optimal for clinical development and practice. Thus, we have

the following, for example: standardized cultural competency training modules in

which ‘competence’ about diversity can be measured to track practitioner

‘improvement’ in understanding cultural difference, and the slippage between

categorical vs. reflexive thinking these modules produce (Shaw and Armin; Jenks);

the rise of computer based Health Information Technology systems designed to

reduce clinical error but which actually conceal labor shortages in the nursing

profession that may be the true cause of higher rates of medical error (Pine); the

problem-oriented patient presentation that creates both a ‘‘categorizable, recogniz-

able and generic’’ patient/case and a professional physician but dehumanizes the

patient and the doctor–patient relationship (Holmes and Ponte); the use of students-

in-training to serve the globally and locally underserved and uninsured and the

mystification, rather than exposure, of local and global social inequalities (and

cultural stereotyping) that these reproduce (Brada, Rivkin-Fish); the standardized

simulated patient performance, considered the best method (because it is

standardized) for representing illness and suffering and thus for measuring ‘‘clinical

skills’’ but that also becomes a site for ethical induction and innoculation (Taylor);

and the jarring ethnographic possibility of breakthrough moments when reflexivity

enables the health professional to reflect critically on biomedicine and embrace the

possibility of ‘‘not knowing for sure’’ what to do (Stonington). The authors in this

volume agree that clinicians come to embody the logics of a new clinical gaze

through those tools. That is, clinicians learn what to recognize about patients and
about themselves through those tools of medical reform. ‘‘Re-skilling’’ technologies
and educational strategies mandate new ways of knowing patients, systems of

service delivery and above all, the new kinds of ethical opportunities that clinicians

need to embrace.

The entrenched moral economies of health care settings shape clinician

sensibilities as well, as many of the articles in this collection show. Here, the

analysis of misrecognition is as important as that of recognition. ‘‘Skilling’’ health
professionals for work in ‘resource-poor’ and ‘community’ settings, for example,

ends up reinforcing stereotypes of the poor as responsible for their ill health and

treating cultural difference as a problem of medical incompetence. Such efforts sit

awkwardly next to the growth of required programs in cultural competency across

US medical schools. Deliberation over how to appropriately represent ‘‘cultural

Cult Med Psychiatry (2011) 35:313–320 317

123

difference’’ as a problem of self vs. other may or may not be hitting the mark if

larger problems of abject poverty and the commodification of health (literally—one

has to be able to afford health to have it) are overlooked. These problems of

commodified health care infrastructures are deeply vexing to professionals,

including those in training, when they are asked to engage in efforts to both save

money and organize their treatments and caregiving in ways that are not ideal and,

in fact, at odds with their reasons for such a career choice. Here too are problems of

misrecognition.

When read as a group, the essays raise important questions about how to enable

and empower health professionals who want to engage in activism, social justice,

and socio-political reform without transmuting these efforts into personal strategies

for ethical choice. How can the ethical struggles of health professionals in training

today be made to bear fruit in the real world? Health professionals arrive to their

training with pre-formed ideas about the sources and causes of the health problems

they will confront. What is the responsibility, then, of the institutions that teach

them, and what sort of ethics become embodied in the choices these schools make

about how and what kinds of training will be required? Where misrecognitions are

seen with the institutionalization of things like ‘‘cultural competency,’’ ‘‘rural

service work,’’ ‘‘simulated trauma’’ or even ‘‘SOAP’’ notes, we might also pose the

question of how to better prepare students in the health professions for a life of

clinical work—in which patient problems extend far beyond what they ‘‘present’’ in

the clinic; treatment options have less to do with standard of care and more to do

with the uneven distribution of resources; and health professional understandings of

patient problems and treatment options reach deep into the kinds of cultural

knowledge(s) that are shaped and reproduced by the structural inequalities of the

larger (global) health care delivery landscape. Efforts toward social justice and

health advocacy start, as these articles illustrate, with individual ethical reflection on

the nature of one’s work, one’s place in the world, and one’s personal sense of

effectiveness as a health professional, but such personal commitments can have

effects far beyond one’s expectations. The articles are an outstanding start for

re-invigorating discussion about medical pedagogy and practice in today’s market-

based context for health care delivery.

Finally, this collection offers an important new methodological insight. The

articles, without explicitly stating so, reveal how ethnography can serve as both a

social scientific method and a unique approach to medical practice. These articles

take medical anthropology beyond a critique from the outside, beyond analyses of

biomedicine as a cultural system. They show that ethnography can be useful for

remaking the ‘‘medical citizens’’ Rosenberg hopes for so that they can practice with

a greater knowledge of the socio-cultural-economic sources of inequity and thus

with some conceptual tools for their amelioration.

The volume Lock and Gordon assembled in 1988 illustrated that biomedicine is

not objective, neutral and universal. Their goal was to show how social science

exploration of the inner logics, local practices and social production of the many

forms of biomedicine might improve knowledge about the rationales for actual

practices. The articles in this collection highlight some of the still recalcitrant

rationales for practice (cultural stereotyping; reducing the patient to assessment,

318 Cult Med Psychiatry (2011) 35:313–320

123

plan, etc.), and they describe the more recently adopted justifications for

streamlining, quantifying and generalizing training techniques. But going farther,

this CMP collection recognizes that many of the problems that have plagued

medicine are not going away and that some are being introduced or re-introduced

through new technologies and fiscal mandates. Efforts to standardize training by

using real people as simulated patients still create ‘‘cases’’ that can be fragmented

into objectivized parts, even when the real life problems of simulators bleed into the

‘‘fake’’ performance of disease. Political economic critiques that lead to reforms in

health care training and make it possible for students to serve poor patients may

only reproduce the social inequalities they seek to redress. The routinization of

medical practices aimed at generating better standards of care may distance patients

from their caregivers in new and frightening ways.

These articles suggest that new types of medical and caregiving engagements

may be possible through careful ethnography. No longer are health professionals

fully caught in the webs of objectification and reductionism that come along with

enculturation in the medical profession; caregivers in training are themselves not

uniform nor uniformly positioned in their ethical embrace of market-based

mandates. They struggle with how to be and with how to see their efforts in

ways that will serve their patients and resonate with the kind of medical citizen they

wish to become. The authors show how ethnographic methods can be part of the

arsenal of doing ‘‘medicine in its largest social sense’’ (to refer back to Rosenberg).

Efforts to overcome the boundaries of disciplinary divides between anthropology,

medical anthropology, and medicine are, perhaps the strongest contribution of this

collection. We applaud the editors and contributors for using ethnography as a

potential intervention in clinical practice and training.

References

Conrad, P.

1992 Medicalization and Social Control. Annual Review of Sociology 18: 209–232.

Fox, R.C.

1957 Training for Uncertainty: Introductory Studies in the Sociology of Medical Education. In The
Student Physician. R.K. Merton, G. Reader, and P.L. Kendall, eds., pp. 207–241. Cambridge:

Harvard

University Press.

1980 The Evolution of Medical Uncertainty. The Milbank Memorial Fund Quarterly. Health and

Society 58(1): 1–49.

1990 The Evolution of American Bioethics. In Social Science Perspectives on Medical Ethics.
G. Weisz, ed., pp. 201–220. Dordrecht, Boston: Kluwer Academic Publishers.

2000 Medical Uncertainty Revisited. In Handbook of Social Studies in Health and Medicine. G.L.
Albrecht, R. Fitzpatrick, and S. Scrimshaw, eds., pp. 409–425. London; Thousand Oaks, CA:

Sage Publications.

Freidson, E.

1970 Professional Dominance: The Social Structure of Medical Care. New York: Atherton Press.

Good, M.J.D.V.

2001 The Biotechnical Embrace. Culture Medicine and Psychiatry 25(4): 395–410.

Gordon, D.

1988 Tenacious Assumptions in Western Medicine. In Biomedicine Examined: Culture, Illness, and
Healing. M.M. Lock and D. Gordon, eds., pp. 19–56. Boston: Kluwer Academic Publishers.

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Illich, I.

1982 Medical Nemesis: The Expropriation of Health. New York: Pantheon Books.

Lock, M.M., and D. Gordon

1988 Biomedicine Examined. Boston: Kluwer Academic Publishers.

Navarro, V.

1976 Medicine under Capitalism. New York: Prodist.

Rosenberg, C.E.

2007 Our Present Complaint: American Medicine, Then and Now. Baltimore: Johns Hopkins

University Press.

Young, A.

1982 The Anthropologies of Illness and Sickness. Annual Review of Anthropology 11: 257–285.

Zola, I.

1972 Medicine as an Institution of Social Control. The Sociological Review 20(4): 487–504.

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Rev. Latino-Am. Enfermagem
2010 May-Jun; 18(3):459-66

www.eerp.usp.br/rlae

Corresponding Author:

Flavio Braune Wiik
Universidade Estadual de Londrina. Centro de Letras e Ciências Humanas.
Departamento de Ciências Sociais
Campus Universitário. Caixa-Postal 6001
CEP 86051-990 Londrina, PR, Brasil
E-mail: flaviowiik@gmail.com

Anthropology, Health and Illness: an Introduction to the Concept of

Culture Applied to the Health Sciences

Esther Jean Langdon1

Flávio Braune Wiik2

This article presents a reflection as to how notions and behavior related to the processes of

health and illness are an integral part of the culture of the social group in

which they occur.

It is argued that medical and health care systems are cultural systems consonant with the

groups and social realities that produce them. Such a comprehension is fundamental for the

health care professional training.

Descriptors: Culture; Anthropology; Health Care; Health Sciences.

1 Anthropologist, Ph.D. in Anthropology, Full Professor, Universidade Federal de Santa Catarina, SC, Brazil.

Email: estherjeanbr@gmail.com.
2 Social Scientist, Ph.D. in Anthropology, Adjunct Professor, Universidade Estadual de Londrina, PR, Brazil.

Email: flaviowiik@gmail.com.

Original Article

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Antropologia, saúde e doença: uma introdução ao conceito de cultura

aplicado às ciências da saúde

O objetivo deste artigo foi apresentar uma reflexão de como as noções e comportamentos

ligados aos processos de saúde e de doença integram a cultura de grupos sociais onde

os mesmos ocorrem. Argumenta-se que os sistemas médicos de atenção à saúde,

assim como as respostas dadas às doenças, são sistemas culturais, consonantes com os

grupos e realidades sociais que os produzem. A compreensão dessa relação se mostra

fundamental para a formação do profissional da saúde.

Descritores: Cultura; Antropologia; Atenção à Saúde; Ciências da Saúde.

Antropología, salud y enfermedad: una introducción al concepto de

cultura aplicado a las ciencias de la salud

Este artículo presenta una reflexión acerca de como las nociones y comportamientos

asociados a los procesos de salud y enfermedad están integrados a la cultura de los

grupos sociales en los que estos procesos ocurren. Se argumenta que los sistemas

médicos de atención a la salud, así como las respuestas dadas a la enfermedad son

sistemas culturales que están en consonancia con los grupos y las realidades sociales

que los producen. Comprender esta relación es crucial para la formación de profesionales

en el área de la salud.

Descriptores: Cultura; Antropología; Atención a la Salud; Ciencias de la Salud.

Introduction

Perhaps it seems out of place to address the theme

of culture in a journal dedicated to the Health Sciences

or to argue that the concept of culture can be useful

for professionals of this area. Everyone has a common

sense idea of what “culture” means. We say that a person

“has culture” when he or she has a higher education,

comes from a family of a good socio-economic level or

understands the arts and philosophy. It is normal to

consider that a “good patient” “has culture” sufficiently

to comprehend and follow correctly the instructions

and warnings given by the health professional. This

patient is contrasted with the one “without culture”, the

more “difficult” patient who acts incorrectly through

“ignorance” or who is guided by “superstitions”.

In this article, we will discuss another notion of

culture, the analytical concept that is fundamental to

anthropology. Culture, as conceived by anthropology,

also serves as an instrumental concept for health

professionals conducting research or health intervention

among rural or indigenous populations, as well as in urban

contexts characterized by patients belonging to different

social classes, religions, regions or ethnic groups. These

patients present unique behaviors and thoughts with

regard to the experience of illness, as well as particular

notions about health and therapeutic practices. These

particularities do not come from biological differences,

but from those that are social and cultural in nature.

In short, our point of departure is that everyone has

culture and that it is essentially culture that determines

these particularities. Moreover, questions related to the

processes of health and illness should be considered from

the perspective of the specific socio-cultural contexts in

which they occur.

This assumption about the role of culture is not

exclusive to anthropological knowledge, and theorists,

researchers and professionals in the health fields

– particularly those in medicine and nursing – have

embraced it since the second half of the 1960s(1-2).

They support the idea that biomedicine is a cultural

system and that the realities of clinical practice should

be analyzed from a transcultural perspective. Likewise,

they draw attention to the relevance of the use of

qualitative methods and techniques in health research, in

particular, the ethnographic method(3). Conjoined to these

reflections, are theoretical and philosophical premises

found at the intersection of health and culture, between

the imponderables observed in practical intervention

by health professionals in the face of cultural theory,

between cultural relativism and universal human rights,

and between the demands of a health profession and the

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Rev. Latino-Am. Enfermagem 2010 May-Jun; 18(3):458-65.

more theoretical and reflexive space of anthropology(4).

This theme has been addressed in the Latin American

Journal of Nursing through publication of results of

studies and research conducted by health professionals

and academics(5-7). Using the ethnographic method and

interpretive analysis, these studies point out that the

patient’s construction of the meaning of illness is central

and which is superimposed upon that of biomedical

causality and rationality. For example, in a study

conducted with oncological patients, it was observed

that the symbolism of radiotherapy from the patients’

perspective and constructed throughout the treatment

process, proved to be a powerful organizer and arranger

of the patient’s experience against disruptions caused

by the disease and its therapy. Likewise, the influence

of religious belief has been observed to positively

affect the survival of total laryngectomy patients who

are surrounded by socio-affective religious networks

accompanying them and praying for their healing.

On the other hand, these studies call attention to the

challenges and paradoxes inherent in the ethnographic

method that require simultaneously the researcher’s

immersion in the quotidian socio-cultural universe of

the group (of patients) to be investigated and distancing

so that the investigator does not assume ethnocentric

postures. They also question the factibility between the

use of interpretivism, which tends toward hermeneutic

subjectivity, and the construction of knowledge according

to scientific objectivity.

An instrumental concept of culture

The universe that encompasses the conceptual

definition of culture is extremely complex and diverse,

the common divisor of anthropology’s various analytical-

theoretical currents and fomenter of their epistemological

and methodological approaches(8-9). Considering the

purpose of this article, we will limit ourselves to discussing

some essential and instrumental aspects linked to the

concept of culture, which, in turn, will be used in the

typological and analytical construction proposed.

Culture can be defined as a set of elements that

mediates and qualifies any physical or mental activity

that is not determined by biology and which is shared by

different members of a social group. They are elements

with which social actors construct meanings for concrete

and temporal social interaction, as well as sustain

existing social forms, institutions and their operating

models. Culture includes values, symbols, norms and

practices.

From this definition, three aspects should be

emphasized so that we can comprehend the meaning

of socio-cultural activity. Culture is learned, shared, and

patterned(10). In affirming that culture is learned, we are

stating that we cannot explain the differences in human

behavior through biology in an isolated way. Without

denying its important role, the cultural(ist) perspective

argues that culture shapes biological and bodily needs

and characteristics. Thus, biology provides a backdrop

for behavior, as well as for the potentialities of human

formation and development. However, it is the culture

shared by individuals of a society that transforms

these potentialities into specific, differentiated, and

symbolically intelligible and communicable activities.

Based on this assumption, being a man or woman, a

Brazilian or a Chinese does not depend on one’s respective

genetic composition, but on how that person, through and

because of culture, will behave or think. Ethnographic

studies on sexual behavior patterns according to gender

have indicated that there are wide variations in the

behavior of the sexes and that these variations are based

on what people have learned from their culture about

what it is to be a man or a woman(11-12).

Culture is shared and patterned, because it is

a human creation shared by specific social groups.

Material forms, as well as their symbolic content and

attributions, are patterned by concrete social interactions

of individuals. Culture is a result of their experiences in

determined contexts and specific spaces, which can be

transformed, shared and permeated by different social

segments. Although the content and forms inherent in

each culture can be understood and replicated individually

– conferring to the culture the character of internalized

and embodied personal experience – the concerns of

anthropology are i) to identify cultural patterns shared

by groups of individuals; ii) to deduce what is common in

the actions, allocation of meaning, and significance and

symbolism projected by the individuals on the material

and “natural” world; iii) to reflect on the experience

of living in society, including of that of becoming sick

and caring for one’s health, as a highly intersubjective

and relational experience, mediated by the cultural

phenomenon.

In order to illustrate our argument, we can observe

different cultural patterns regarding the types of food

and diet. In Brazil, the combination of rice and beans

is fundamental for a meal to be considered complete.

Without them, even with presence of meat, many say

their hunger is not satisfied. Others always need a meat

dish to feel well fed. They can even leave the table

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hungry, after eating a hearty dish of Chinese food filled

with mixed vegetables with little meat. But a Chinese

feels completely satisfied with a primarily vegetarian

meal.

Not only is what to eat determined in a particular

way by culture, but also when to eat as well. Most

Brazilians eat the largest meal of the day at noon to

“digest the food well” and to be “well-fed for work” until

the late afternoon. It is common to claim that eating a

lot at night, especially eating “heavy food” is bad for the

stomach. In turn, North Americans, who do not miss

rice and beans, generally eat less at noon and a large

quantity of “heavy” food (in the eyes of the Brazilians)

in the evening before sleeping. For them, food in

abundance at noon is inappropriate and hinders the

afternoon’s work. From this perspective, culture defines

social standards regarding what and when to eat, as

well as the relationship between types of foods that

should or should not be combined, and, consequently,

the experience of satisfying hunger, or not, is both

socially and biologically determined. It is biology’s task

to indicate basic nutritional needs and to determine the

limitations of foods considered toxic.

In affirming that culture is tied to all physical or

mental activity, we are not alluding to a patchwork quilt

composed of pieces of superstitions or behavior lacking

in intrinsic coherence and logic. Fundamentally, culture

organizes the world of each social group according to its

own logic. It is an integrating experience, holistic and

totalizing, one of belonging and interacting. Consequently,

culture shapes and maintains social groups that share,

communicate and replicate their ways, institutions, and

their principles and cultural values.

Given its dynamic nature and intrinsic politico-

ideological characteristics, culture and the elements

that comprise it are mediating sources of social

transformation, highly politicized, appropriated, modified

and manipulated by social groups throughout their

history, guided by the intentions of the social actors

in the establishing of new socio-cultural patterns and

societal models.

Moreover, each group interacts with a specific

physical environment, and culture defines how to

survive in this environment. Due to the creative and

transformative character, inherent in human cultures, in

interaction with the natural world, we find the existence

of various different solutions for societies’ survival

within the similar environments. Human beings have

the capacity to participate in any culture, to learn any

language, and to perform any task. However, it is the

specific culture into which they are born and/or raised

that determines the language(s) they will speak, the

activities they will develop, and their position and

potential for social mobility in the social structure.

Language, social roles and positions are governed by

age, sex and other cultural variables that influence the

bodily techniques and aesthetic patterns adopted, as well

as the social roles performed according to ideal types

informed by the kinship system and other institutions

of the society to which a person belongs. Finally, in

this dialogue between the individual and society, culture

is both the subject and object. This happens, because

throughout a lifetime, individuals are gradually socialized

by/in the cultural patterns current in their society and

which are constructed through daily social interaction,

as well as through ritual processes and institutional

affiliations. They are responsible for the transformation

of individuals into social actors, into members of a

certain group that mutually recognize each other. As

social actors, they learn and replicate the principles

that guide ideal patterns of valued and qualified types

of action, those of behavior, dress, or eating habits, as

well as techniques for diagnosis and treatment of illness.

Moreover, the socialization of individuals is responsible

for the transmission of meanings about why to do it.

The why to do has special importance as it allows us

to understand the integration and the logic of a culture.

Culture, above all, offers us a view of the world, that is,

the perception of how the world is organized and how to

act accordingly in a world that receives its meaning and

value through culture. Thus, as previously discussed, it

is the culture of a group that provides social actors with a

classification and value system of those foods considered

edible or not, defines the techniques and environments

for obtaining food, and classifies, organizes and assigns

values to various types of food, such as “good”, “weak”,

“strong”, “light”(13).

To present another example: the concept of

cleanliness and hygiene are fundamental categories

present in all cultures. Every culture establishes its

categories of things, classifying them as “clean and

pure” or “dirty and impure”(14), as well as determines

which practices and knowledge are associated with

these categories that contribute to their maintenance,

classification and distinctions. However, the definitions

about what is considered “clean” or “dirty”, “pure” or

“impure” are as varied as the multiplicity of human

cultures found in the world. This variation reflects

a fundamental assertion in the construction of the

field of anthropological knowledge: the paradoxical

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confirmation of the diversity and unity encompassed by

cultural phenomenon that is, at the same time, one and

universal, diverse and specific.

Among the Barasana Indians of the Colombian

Amazon jungle(15), apart from ants with cassava (manioc

bread), the diet consists of meat or fish obtained by the

men and eaten with cassava made by the women. When

a hunter is lucky, upon returning to the longhouse, he

delivers the largest portion of meat to the most senior

man of his extended family. His wife or wives cook the

meat in a large pot and put it on the floor in the center of

the house. Then, the senior man first calls the men to eat

according to hierarchical rules based on age groups and

prestige. Afterwards, he calls the women, though not

always all of them. Children are never called to eat when

the pot contains the meat of large animals or fish.

In addition to the social rules based on hierarchy and

distribution of power that regulate food consumption,

all foods and those who prepare or ingest them, are

regulated by cultural principles of cleanliness and purity,

known by the Barasana as witsioga. Witsioga consists of

a substance present in the food, especially meat, which

is dangerous for small children and people of certain

age groups or in liminal states, such as those entering

puberty or participating in shamanism initiation,

pregnant or women in post-partum, and those who are

ill. Since manioc bread is considered a “pure” food, that

which has been touched by the hand of a person eating

meat is contaminated it for those in liminal states.

The Barasana have a complex classification of

animals and fish that are witsioga. They classify them

according to size, behavior, etc. There are also principles

that regulate a series of practices and actions that can

and cannot be performed after eating meat, besides the

hygienic practices intended to cleanse this substance

from the people who eat meat that contains witsioga.

Witsioga also regulates the diagnosis, origin and etiology

of diseases, and, in turn, is linked to the cosmology of

the Indians. The world is controlled by beings (“spirits”)

and witsioga attracts evil spirits that attack people who

are classified as weak or vulnerable.

This example illustrates that when we are faced

with the customs present in other cultures, we should

try to understand their why. By doing this, we avoid

an ethnocentric comprehension of them, that is, judging

Barasana culture according to our own values and

classification of the world and not according to theirs.

The fact that they eat ants, eat from the same pot, eat

with their hands scooping up food with pieces of manioc

bread, and share a single gourd for drinking, might

cause a certain repulsion, since “ants are not food” and

“eating food from a pot on the floor is dirty”. Also, one

might consider the category witsioga to be “superstition”

since such behavior is opposed to what we comprehend

to be “healthy” and “clean” according to biomedical

rationality.

The anthropological perspective requires that, when

faced with different cultures, we do not make moral

judgments based on our own cultural system and that

we understand other cultures according to their own

values and knowledge – which express a particular view

of the world that orients their practices, knowledge and

attitudes. This procedure is called cultural relativism.

It is what allows us to comprehend the why of the

activities and the logic of meanings attributed to them,

without ranking or judging them, but only, and, above

all, recognizing them as different!

Many other examples could also be drawn from

ethnographic research conducted by the health

professionals cited in this article(4-7). All of them lead

us to reflect on issues related to health habits, rituals,

techniques of care and attention, and restrictions with

regard to the use of therapeutic practices (e.g. blood

transfusion, organ transplantation or even abortion);

all of these are mediated by cultural systems distant

from, or even opposed to, the cultural standards which

underlie the construction of the biomedical system and

with which health professionals are trained.

We have used examples taken from a society

whose culture is very distant, one characterized as a

simple society. However, in a complex society like Brazil,

which, in addition to being stratified by social classes,

is comprised of numerous ethnic groups and population

segments exhibiting diverse religious and regional

customs, we find internal cultural differences and inter-

group variations. Although these groups share aspects

of a general culture, identified as the so-called “Brazilian

culture”, but we must recognize that these collectivities

that make up the Brazilian population have different

views of the world and perceive reality in a diverse

ways, generating a complex and intertwined socio-

cultural mosaic. This complexity is the background of

the context that articulates health, culture and society,

and in which professionals and researchers in the field

of health are inserted.

Culture, society and health

If we accept that culture is a total phenomenon

and thus one which provides a world view for those

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who share it, guiding their knowledge, practices and

attitudes, it is necessary to recognize that the processes

of health and illness are contained within this world view

and social praxis.

Concerns with illness and health are universal

in human life and present in all societies. Each group

organizes itself collectively – through material means,

thought and cultural elements – to comprehend and

develop techniques in response to experiences or

episodes of illness and misfortune, whether individual

or collective. As a consequence, each and all societies

develop knowledge, practices and specific institutions

that may be called the health care system(1).

The health care system comprises all components

present in a society related to health, including knowledge

about the origins, causes and treatments of disease,

therapeutic techniques, its practitioners, and the roles,

standards and agents in interaction in this “scenario”.

Added to these are power relationships and institutions

dedicated to the maintenance or restoration of “the

state of health”. This system is supported by schemes

of symbols that are expressed through the practices,

interactions and institutions; all are consistent with the

general culture of the group, which in turn, serves to

define, classify and explain the phenomena perceived

and classified as “illness”.

Thus the health care system is not disconnected

from other general aspects of culture, just as a social

system is not dissociated from the social organization of

a group. Consequently, the manner by which a particular

social group thinks and organizes itself to maintain

health and face episodes of illness, is not dissociated

from the world view and general experience that it has

with respect to the other aspects and socio-culturally

informed dimensions of experience. Comprehension

of this totality makes it possible to apprehend the

knowledge and practices linked to the health of the

individuals that form a society’s cultural system and

intellectual and moral heritage. Thus, if we do not know

that the Barasana category of witsioga is linked to

their cosmology, to the classification of food and to the

state/status of the people, we do not comprehend the

importance given by them to the ways taken as correct

and “pure” for the preparation and consumption of food.

It would also be difficult to comprehend the importance

of this concept within their concerns for health or to

convince them that in an environment with few sources

of protein, prohibiting meat for young children and

breastfeeding women may affect their growth if they do

not have another adequate protein source.

A health care system is a conceptual and analytical

model, not a reality itself, for the understanding of

social groups with whom we live or study. The concept

helps to systematize and comprehend the complex set

of elements and factors experienced in daily life in a

fragmented and subjective manner, be this in our own

society and culture or in that of an unfamiliar one.

It is important to understand that in a complex

society such as the Brazilian one, there are several

health care systems operating concurrently, systems

that represent the diversity of the groups and cultures

that constitute the society. Although the state medical

system, which provides health services through the

National Health System (SUS), is based on biomedical

principles and values, the population, when sick, uses

many other systems. Many groups do not seek medical

doctors, but use folk medicine; others use medical-

religious systems, and others seek multiple alternative

health systems throughout the therapeutic process. To

think of the health care system as a cultural system

helps us to comprehend this multiplicity of therapeutic

itineraries.

The Cultural System of Health

The cultural system of health emphasizes the

symbolic dimension of the understanding of health and

includes the knowledge, perceptions and cognitions

used to define, classify, perceive and explain disease.

Each and all cultures possess concepts of what it is to be

sick or healthy. They also have disease classifications,

and these are organized according to criteria of

symptoms, severity, etc. Their classification, as well as

the concepts of health and illness, are not universal and

rarely reflect the biomedical definitions. For example, in

Brazil, and mau olhado (evil eye)(16) are folk illnesses

that deny biomedical diagnosis and treatment. These

diseases are classified according to their particular

symptoms and causes that guide their diagnosis and

therapeutic practices chosen. Only folk specialists have

the knowledge to diagnose and treat them.

In this way, culture provides etiological theories

based on the worldview of a group, and these theories

can frequently indicate multiple causes for an illness

episode, and they can be thought of as “mystical” and/

or “non-mystical”. Among the “non-mystical”, or natural

causes, we find theories and perceptions about the body

that attribute its poor functioning to the ingestion of

certain inadequate foods, climate, social relationships

or work conditions. These theories, in turn, provide

a basis for preventive medicine linked to behavior and

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Langdon EJ, Wiik FB.

hygiene, as well as to elements linked to a curative

medicine. The “mystical” causes frequently combine with

the “non-mystical” and may indicate the need for more

than one type of treatment, for example: one to heal the

physical body and another to heal the spiritual or social

body(17). Etiological theories that include “natural causes”

are accompanied by treatments based on knowledge

of herbs and techniques of body manipulation to treat

bodily symptoms. Ignorance or negation of their efficacy

demonstrates the bioscientific ethnocentrism often present

when evaluating other cultural systems of health care.

The Social System of Health

The system of health care is both a cultural system

and a social system of health. The social system of health

is composed of its institutions, organization of the health

specialists’ roles, rules of interaction, as well as power

relationships inherent to it. Commonly, this dimension

of the system of health care also includes specialists not

recognized by biomedicine, such as folk healers (massage

therapists, benzedeiras, curandeiros) or religious and

faith healers (pastors, priests, benzedeiras, shamans,

spiritists, and others), shaman, pajés, pais-de-santo).

In the world of each social group, experts have

a special role to perform concerning the treatment of

illness, and patients have certain expectations about how

this role will be developed, which illnesses the specialist

can cure, as well as a general idea about the therapeutic

methods he will employ.

In complex societies, besides the traditional

specialists mentioned above, we also find practitioners

of Chinese and Oriental medicine. In the last ten years

we have also seen a growing demand for practitioners

and therapists belonging to what has been called the

“new age”(18). Within the same city, there are specialists

practicing several alternative therapeutic methods

(reflecting different cultural systems of health care),

which are selected or rejected according to factors such

as religion, economic conditions, family experience and

social networks, as well as other political and/or legal

factors (such as the persecution by the State of a given

nonofficial therapeutic practice)(16).

Studies in Health, Culture and Society in Brazil

In Brazil, studies and research on health, culture

and society have multiplied significantly in the last

twenty years(19). In the last decade, Anthropology of

Health has been consolidated as a space for reflection

and for academic and professional training of doctors,

nurses and other professionals in the Area of the Health

of the country(19). There are interdisciplinary university

centers and research groups involving anthropologists

and researchers and intellectuals of collective and public

health, dedicated to the investigation of cultural, social

and politico-economic aspects linked to health issues(19).

Some publication collections have discussed the

experience of sickness and the sick body in light of issues

such as gender, religion, representations of healing and

illness narratives(20-21). Recent ethnographies describing

medical contexts, such as hospitals or clinics, have been

published(22-23). The Editor of the Foundation Oswaldo

Cruz (FIOCRUZ) has published the Anthropology and

Health Collection since the mid-1990s, whose volumes

have contributed to the dissemination of production

originating from research centers and national graduate

programs directed toward the area of health. Reports in

Public Health, also published by FIOCRUZ, has produced a

large number of articles focused on contemporary health

issues, such as STD/AIDS, structure and functioning

of health services, evaluation of health policies and

indigenous health.

Conclusions

Although subject to internal contradictions and,

consequently, potential sources of predicaments, the

values, knowledge and cultural behavior linked to

health form a socio-cultural system which is integrated,

holistic and logical. Therefore, issues relating to health

and sickness cannot be analyzed in isolation from

other dimensions of social life that are mediated and

permeated by cultural meaning. Health care systems

are cultural systems, compatible with human groups

and their social, political and economic realities that

produce and replicate them. Accordingly, for theoretical

and analytical purposes, the biomedical system of health

care should also be considered a cultural system, as any

other ethnomedical system. Therefore, interpretations

of and interventions in health and illness processes – be

they observed for individuals-patients or for biomedically

trained health professionals – must be analyzed and

evaluated using the concept of cultural relativism, thus

avoiding, ethnocentric attitudes and analysis by these

professionals and theorists.

In the end, we are all subjects of culture and

experience it in several ways, including when we become

sick and seek treatment. However, when we act as

professionals and researchers from the Area of Health,

we encounter cultural systems different from our own

(or in which we have been trained), without applying

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relativism to our own medical knowledge. This happens,

especially in the health field, because in the modern

and rational West, we naturalize the medical field,

attributing to it universal and absolute truth, distancing

it from culturalized forms of knowledge, where truth is

particular, relative and conditional.

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Received: Ap. 22th 2009

Accepted: Nov. 16th 2009

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