cultures where hunting is fundamental to success, failure in hunting may be viewed as illness. Similarly, poverty and unemployment may be regarded as a form of illness, with the unwanted condition increased by social evaluations that affect self-concept and self-esteem. Culturally important or stigmatized bodily conditions (fat, skinny, weak, dark-skinned), personality characteristics, or emotions (aggression, shyness, greed, rage) may also be regarded as unwanted conditions. Even biological aspects of disease are affected by cultural perceptions, which may defi ne as healthy a symptom or condition viewed as evidence of disorder in another culture. For instance, in areas of the Amazon where parasitic skin disease is endemic, the people who are considered abnormal are those whose immune systems provide immunity to the disease. The illness bearer’s assessment of conditions as being a threat to oneself may come at any level:
body, personality, mind, or connection with the physical, social, or spiritual world.
Clinical Signifi cance of African American High-Pertension
African American beliefs about hypertension (or “high-pertension”) and “high blood” are similar to biomedical concepts of hypertension and high blood pressure and pose risks for mis- understanding in medical contexts. Hypertension is defi ned from a biomedical perspective as specifi c systolic and diastolic blood pressures (above 140 and 90 millimeters of mercury, respectively), with high blood pressure increasing the risk for cardiac diseases and strokes, kid- ney diseases, and other circulatory complications. High-pertension is related to nerves, stress, and excitable emotional reactions. Like high blood, it involves blood rising up to the head but much more rapidly and with the possibility of causing immediate death. African American concepts of high-pertension and high blood express concern with the amount of blood located high in the body, with excessive blood in the brain leading to headaches, disorientation, dizzi- ness, fainting, strokes, and even death. High-pertension is thought to result from a variety of factors: diet (high levels of fat and rich foods and seasonings), stressful events, excessive alcohol consumption, and supernatural causes (evil spirits or hexes). Health beliefs regarding dietary treatments of high blood and high-pertension are important for biomedical practition- ers because similar terms (hypertension and high blood pressure) complicate communication about and management of the conditions (Schoenberg, 1997). Clinicians’ diagnosis of high blood pressure may lead patients to rely on traditional remedies to produce “low blood” (eat- ing salty foods, vinegar, and pickled food) that directly confl ict with what is advisable for high blood pressures. Heurtin-Roberts (1993) illustrates that high-pertension is a mechanism of personal adaptation for addressing problems related to stress, tension, and anxiety. Hyperten- sion is believed to affect the heart and provides a mechanism for manipulating social relations and alleviating demands to be a caretaker for others. Because hypertension can cause death if the person is emotionally excited, it can be used to reduce demands from others and con- trol the emotional tone of social interactions, especially with family and friends.
CULTURE AND HEALTH
c02.indd 61
c02.indd 61 9/22/08 3:16:24 PM9/22/08 3:16:24 PM
Popular conceptions of illness are much broader than the clinical concept of disease, involving a balance of the individual with natural, social, and supernatural worlds.
Illness and sickness have broader concerns with psychological, social, and moral issues that have implications for the self.
The inability of providers to address clients’ culturally based conceptions of their con- ditions can create a range of problems in the context of clinical consultation. The discus- sions of caida de mollera (Chapter One) and of “high-pertension” show that ignoring clients’ conceptual frameworks can lead to the neglect of serious biomedical conditions or contraindicated folk treatments.
Illness Narratives
Frank’s (1995a, b) work on illness illustrates the powerful role of the illness accounts that patients provide in restoring their sense of empowerment, agency, and care of the self.
These narratives allow them to cast off the stigmas that have been ascribed to them and their condition, rewriting their medical history and recovery in intelligible terms. These narratives may connect them with social networks of similar sufferers who turn their stig- matized condition into a fi ght for basic human rights (e.g., the AIDS movement). Or their dialogues may reconstruct their situation in honorable terms, alternative histories that char- acterize the formation of their victim status or their heroic efforts to heal despite dismal odds of success. These stories of success can provide the motivation for overcoming the limitations imposed by a malady or adjusting one’s life to cope with the circumstances. In this sense, illness stories may convey the effort to succeed despite medical conditions.
Brody (1987) shows that among physicians, stories are ways of illustrating how gen- eral scientifi c knowledge is applied to individual cases, with anecdotes providing a link between scientifi c knowledge and particular patient problems. Illness narratives (Loewe, 2004) are also an important source of information for educating providers and consumers about the impacts that disease and diagnosis have on people’s lives, addressing the desta- bilizing effects that maladies—and biomedical treatment—have. These accounts also help contextualize the abstract diagnoses of diabetes or CVD within the context of its effects on day-to-day existence. The importance of addressing patients’ experiences of ill- ness and their narratives about them is illustrated in Mattingly’s (1998) Healing Dramas and Clinical Plots and Mattingly and Garro’s (2000) edited book, Narrative and the Cul- tural Construction of Illness and Healing. Narratives help reveal the personal experience of a malady and the broader linkages of sufferers’ situations to the cultural environment and social milieu within which they function. These narratives can reveal problems with treatment, complications with patient compliance, and challenges in everyday life posed by both the malady and the treatment.
Illness narratives and stories of sickness that physicians and patients share about mala- dies address broader social implications of the malady and its explanation: the why, what, when, where, and how that explain the occurrence, treatment, and resolution of a malady.
For patients, stories of sickness involve placing their experiences in the broader social context, the labeling and classifi cation of their experiences for others, thereby link- ing the individual and social dimensions within a patient’s life experience and meanings
c02.indd 62
c02.indd 62 9/22/08 3:16:25 PM9/22/08 3:16:25 PM
Healing Stories from Jewish Women Saints
Sered’s (2005) examination of the curative roles of pilgrimage illustrate how patients’ experi- ences of suffering are framed in the models provided in the stories associated with the mytho- logical “Rachels,” the shared name of three Jewish female saints. Their mythical representations provide models of personal suffering and endurance for women’s management of grief and loss.
Through storytelling, mythological models become entwined with one’s self-identity and dynam- ics, supporting the renouncement of one’s personal needs in service to others. The mythical stories provide a tangible presence for modeling one’s behaviors, reinforcing an ability to endure personal loss through the mythical models provided for the transcendence of suffering.
Healing takes place by associating women’s lives with those of the saints, placing their situations in analogy with the models of myth. This linking of personal circumstances and cosmic order provides meaning in a way that unburdens the self by placing its circumstances within the meaningful cosmic patterns of the universe. Sered shows how women are able to invoke their own mythical model of the universe that resonates with their personal experi- ences, allowing them to heal from the cognitive reinforcement that comes from feeling that one’s own experiences and feelings are shared with others. These therapeutic transference and release processes are enacted in a pilgrimage to the shrines of the saints, where women unburden their loss of children, spouses, and parents and their life sufferings.
Healing stories often involve pilgrimage, a journey to a shrine where the sufferer joins with others in a quest for hope. When healing stories are reinforced through pilgrimage, the physical voyage with others provides a broader social context for the transformation of iden- tity and suffering (Winkelman and Dubisch, 2005). Or if successful, the healing process pro- duces a self-transformation, where a resolution of emotional problems, psychological trauma, and other forms of social suffering release one to psychological growth. The social engage- ment with stories can provide an opportunity for relieving burdens or constructing a new identity as a survivor. Even if physical impairments and disease are not addressed, these social processes may provide important mechanisms for healing as opposed to cure, coming to terms with one’s condition, the permanence of one’s limitations due to disease.
(Whaley, 2000). Storytelling creates connectedness that provides understanding through linking the sufferer’s past and social context, giving an acceptable explanation within the patient’s worldview that provides a sense of confi dence of eventual mastery over illness.
The placement of sickness stories within religious or mythical contexts provides psycho- logical integration by linking the individual’s suffering to broader contexts of positive expectations or endurance.
The importance of storytelling in Native American illness experiences is illustrated by Tom-Orme (1988, 2006). These stories express a worldview that links personal and
CULTURE AND HEALTH
c02.indd 63
c02.indd 63 9/22/08 3:16:25 PM9/22/08 3:16:25 PM
cultural elements in a holistic perspective that helps to explain why illness happened.
Stories articulate relationships between the human and spirit worlds that are essential to balance and harmony. Storytelling can help improve provider-client relationships and communication if they are effectively incorporated into the medical encounter. This requires that providers take worldview differences into consideration with an open mind, Stories of Illness as Healing Devices
Brody (1987) examined patients’ stories of sickness to understand their roles in healing processes. Healing processes are elicited by social activities of telling stories regarding those pro- cesses. Patients use stories to deal with the suffering produced by the meanings they have attached to their experiences and to produce healing or “whole-ing” through attaching particu- lar meanings to their malady and its context within their life.
Pennebaker’s (2003) investigations of the effects of stories of illness on sufferers illus- trate that they are powerfully healing. His research found that patients who shared their sto- ries of illness showed clinically measurable improvements in immune system functioning.
Jewish Americans (holocaust survivors) who took a “let sleeping dogs lie” approach to their internment trauma had poorer immune outcomes than those who expressed their traumatic past in a “confession is good for the soul” approach to reliving these experiences. These con- fessions provided a narration of life and self that fi t with cultural norms regarding the sharing of experiences as a part of the mourning process. The process of telling stories of one’s mal- ady provides meaning to life experiences.
The suppression of trauma causes disease, and the sharing and release of trauma are a part of the healing process. Putting traumatizing experiences into words and sharing them with others in a coherent narrative regarding their meaning and signifi cance for people’s lives brings them from the margins of consciousness, where they are actively repressed, into an emotional release. The healing power of storytelling, of illness narratives, derives in part from the way in which the stories’ expression transforms how we understand the trauma and how we think and respond to it emotionally. The creation of the story of illness provides a narrative that assists in confronting the anxiety produced by trauma.
The story makes the occurrence of illness or trauma and its impact, consequences, out- comes, and implications manageable. Words defi ne maladies in ways controlled and managed within the patient’s conceptual frameworks. Stories assist in management of the emotional effects of the traumatic experiences, leading to improvement in both physical and mental health (Pennebaker, 2003). Stories have a coherent narrative, a logic and consistency that allow still-disturbing or anomalous aspects to be ignored or rationalized. Pennebaker suggests that words also have the power to reformulate the experience and defi nitions of self, empower- ing by defi ning the nature of the previously vaguely experienced trauma in reference to a social context.
BIOCULTURAL INTERACTIONS
c02.indd 64
c02.indd 64 9/22/08 3:16:25 PM9/22/08 3:16:25 PM
create an environment to receive and share stories, and demonstrate patience that allows a trusting relationship to develop (Tom-Orme, 1988, 2006). This means accepting a view of health that is not merely related to biology and disease but one in which healing includes concepts of balance among the physical and social worlds, one’s emotions, social relations, mental state, and spiritual relations. Religious views often play an impor- tant role in determining how individuals relate to their malady and signifi cant others.