Byron J. Good

Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research

Major health care problems such as patient dissatisfaction, inequity of access to care, and spiraling costs no longer seem amenable to traditional biomedical solutions. Concepts derived from anthropologic and cross-cultural research may provide an alternative framework for identifying issues that require resolution. A limited set of such con- cepts is described and illustrated, including a fundamental distinction between disease and illness, and the notion of the cultural construction of clinical reality. These social science concepts can be developed into clinical strategies with direct application in practice and teaching. One such strategy is outlined as an example of a clinical social science capa- ble of translating concepts from cultural anthropology into clinical language for practical application. The implemen- tation of this approach in medical teaching and practice requires more support, both curricular and financial.

The heart of what's the matter. The semantics of illness in Iran.

Our understanding of the psychosocial and cultural dimensions of disease and illness is limited not merely by a lack of empirical knowledge but also by an inadequate medical semantics. The empiricist theories of medical language commonly employed both by comparative ethnosemantic studies and by medical theory are unable to account for the integration of illness and the language of high medical traditions into distinctive social and symbolic contexts. A semantic network analysis conceives the meaning of illness categories to be constituted not primarily as an ostensive relationship between signs and natural disease entities but as a ‘syndrome’ of symbols and experiences which typically ‘run together’ for the members of a society. Such analysis dirests our attention to the patterns of associations which provide meaning to elements of a medical lexicon and to the constitution of that meaning through the use of medical discourse to articulate distinctive configurations of social stress and to negotiate relief for the sufferer. This paper provides a critical discussion of medical semantics and develops a semantic network analysis of ‘heart distress’, a folk illness in Iran.

CULTURE AND DEPRESSION Studies in the Anthropology and Cross-Cultural Psychiatry of Affect and Disorder

Some of the most innovative and provocative work on the emotions and illness is occurring in cross-cultural research on depression. Culture and Depression presents the work of anthropologists, psychiatrists, and psychologists who examine the controversies, agreements, and conceptual and methodological problems that arise in the course of such research. A book of enormous depth and breadth of discussion, Culture and Depression enriches the cross-cultural study of emotions and mental illness and leads it in new directions. It commences with a historical study followed by a series of anthropological accounts that examine the problems that arise when depression is assessed in other cultures. This is a work of impressive scholarship which demonstrates that anthropological approaches to affect and illness raise central questions for psychiatry and psychology, and that cross-cultural studies of depression raise equally provocative questions for anthropology.

American oncology and the discourse on hope

From the perspective of medical anthropology and comparative research, American oncology appears as a unique variant of international biomedical culture, particularly when contrasted with oncological practice in societies such as Japan and Italy. Based on interviews with 51 oncologists in Harvard teaching hospitals, this paper argues that American oncological practice draws on distinctive cultural meanings associated with “hope” and is infused with popular notions about the relationship between psyche and soma, the progressive efficacy of biotechnical interventions, truth-telling, and the nature of the physician-patient relationship.

The Meaning of Symptoms: A Cultural Hermeneutic Model for Clinical Practice

Any good doctor knows … that the patient’s complaint is more extensive than his symptom, and the state of sickness more comprehensive than localized pain or dysfunction. As an old Jew put it (and old Jews have a way of speaking for the victims of all nations): “Doctor, my bowels are sluggish, my feet hurt, my heart jumps — and you know, Doctor, I myself don’t feel so well either.” (Erikson 1964:51)

The place of culture in DSM-IV.

This paper critically reviews the process and outcome of an effort to enhance the cultural validity of DSM-IV and outlines recommendations to improve future diagnostic systems. An ordered presentation of the antecedents and the main phases of this developmental effort is followed by a content analysis of what was proposed and what was actually incorporated, and a conceptual analysis of underlying biases and their implications. The cultural effort for DSM-IV, spearheaded by a scholarly independent NIMH workgroup, resulted in significant innovations including an introductory cultural statement, cultural considerations for the use of diagnostic categories and criteria, a glossary of culture-bound syndromes and idioms of distress, and an outline for a cultural formulation. However, proposals that challenged universalistic nosological assumptions and argued for the contextualization of illness, diagnosis, and care were minimally incorporated and marginally placed. Although a step forward has been taken to introduce cultural elements in DSM-IV much remains to be done. Further culturally informed research is needed to ensure that future diagnostic systems incorporate a genuinely comprehensive framework, responsive to the complexity of health problems in increasingly multicultural societies.

Toward a Meaning-Centered Analysis of Popular Illness Categories: “Fright Illness” and “Heart Distress” in Iran

In recent publications, Marsella outlined an approach to cross-cultural psychiatric epidemiologies. He suggests that such studies begin with an “emic determination of disorder categories”, utilizing ethnoscience techniques “to evolve categories of disorder and their experiential components which are meaningful to the cultures under study” (Marsella 1978:351; cf. Marsella 1979:246; 1980:49). These illness categories should then be submitted to epidemiological research, establishing baseline data and using multivariate analysis to determine objective patterns of disorder for particular societies. Such culture-specific studies should precede cross-cultural comparison. This approach will be welcomed by many anthropologists as having significant advantages over traditional psychiatric epidemiologies, of the sort Kleinman has called “the old transcultural psychiatry” (Kleinman 1977). Anthropologists experienced in studying illness across cultures will recognize also that the most fundamental aspect of such research — the emic determination of categories of disorder — is fraught with important methodological and theoretical difficulties.

Ritual, the state, and the transformation of emotional discourse in Iranian society

This paper explores the social and cultural organization of Iranian emotional discourse and its transformation in post-revolutionary Iran. First, the Moharram dramas we participated in during field research are described, indicating how these performances organized a ‘prototypical’ view of the social order, the self, and the passions. Using Kapferers distinction between “transcendental” and “transformative” rituals, we argue that these dramas were traditionally organized as “transcendental” rites. Second, data on grieving rituals and depressive illness among Iranians is introduced, focusing on the “transformative” qualities of mourning rites and suggesting an interpretation of depression as a failure of the “work of culture.” Third, the appropriation of these symbolic forms of society, self, and the emotions by the current Iranian Islamic state and the role of the state in defming the meaning and legitimacy of emotions and their expression is analyzed.

The Semantics of Medical Discourse

Steven Toulmin (1977) recently observed that during the 1960’s, students of the history and philosophy of science began to shift their attention from the comfortable study of the inner logic of scientific systems — the genetic history of science — toward a serious examination of the relationship of scientific systems to other aspects of society. As it became politically fashionable to expose the link between scientific practices and the interests of those who support it, and as it became theoretically clear that changes in scientific systems are linked to broader social changes, the easy divorce between studies of scientific ‘context’ and ‘content’ was recognized as impossible. As a result, the prohibition against confusing formal or logical issues with empirical matters broke down, and philosophers began to move beyond studying the formal logic of scientific knowledge to studies of scientific practice. Among historians of science, the clarity of the distinction between issues ‘internal to’ the intellectual development of the various sciences and their ‘external context’ was called into question, and studies previously considered unsound — studies of the social and institutional context of science, of the role of economic motivation and political priority in the shaping of scientific practice — became legitimate.

Social status and fertility: A study of a town and three villages in Northwestern Iran

Summary Studies of the relationship between social status and fertility in developing societies have shown diverse results. This study suggests that such findings result in part from problems in the conceptualization of social stratification and social status. In developing societies such as Iran the differentiation of modern and traditional cultural (and occupational) groups within social classes has resulted in the emergence of a dual hierarchy. Measures of social status must therefore reflect these conceptually distinct hierarchies, rather than be limited to linear scales. Figures from a study in a town and three villages in northwest Iran undertaken in 1973 are analyzed. Findings indicate that for women in towns, as social status increases within both traditional and modern occupational hierarchies (husbands occupation) and as measured by income, education and index of modern items, there is a general and almost monotonic decrease in the number of living children, children ever-born, and ideal number of children, with an increase in age at marriage and contraceptive use. The social and cultural homogeneity of the village sample is reflected in the relatively small variations in fertility-related behaviour and attitudes; however, fertility differences between landed and landless villages appear similar to the pattern found in the urban samples. The differences in the fertility behaviour of village and urban women of similar income and educational status indicate that fertility behaviour is related partially to class and partially to status distinctions between urban and rural communities.