The limitations of the biomedical perspective that disease is basically physiological and that mental and psychosocial issues are irrelevant led Engel (1977, 1980) to introduce the biopsychosocial model discussed in Chapter One. Understanding the nature of health and addressing maladies require this broader perspective concerned with the psychological, cultural, and social dimensions affecting well-being. Effective assessment requires an understanding of psychological and social aspects of unwanted conditions, linking diseases and symptoms to the cultural context within which the malady is produced and experi- enced. Constructivist perspectives point out that cultural values produce cross-cultural variation in the recognition of diseases, the signifi cance of symptoms, their treatments, and their consequences. The differences are manifested in the distinction between physi- cians’ concern with disease and patients’ experience of illness, differences that affect the diagnostic processes. Cultural criteria determine the meaning of a given set of behaviors
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provides enhanced immune system responses for both mother and embryo. Callahan proposes that the consumption of dirt in pregnancy and early childhood is an evolutionary adaptation that has a variety of adaptive consequences, including enhancing the development of fetal immunity.
Universally, early childhood (before two years old) is the most prevalent time of geophagy;
Callahan notes that the period of intense dirt ingestion corresponds to the time (one year and more after birth) when immunoglobulin levels provided in mother’s milk begin to decline. The early expo- sures to bacteria provide the basis for developments that enable appropriate immune system responses later in life. Eating dirt appears to provide adaptive benefi ts by stimulating the immune system. The gut is the primary area for the production of immunoglobulin. Exposure to dirt may assist in the development of intestinal fl ora and provide exposure to germs that strengthen immune responses to later threats. Aluminum salts found in dirt can assist in the immune response by functioning as adjuvants that provide a nonspecifi c amplifi cation in the immune sys- tem response (Callahan, 2006). Thus dirt-eating likely has a variety of health benefi ts. Although the practice poses risks for exposures to a variety of helminthic (worm) and other parasitic infec- tions, considering it merely a disease makes little empirical sense. Biomedical perspectives refl ect a particular cultural viewpoint that in most cases is unrelated to the biological and cultural realities of the behavior.
or symptoms as disease or normal variation in behavior, such as in dyslexia, depression, mental retardation, and “dirt eating.”
The facts of biomedicine are based in social processes of the construction of mean- ing, just as with other ethnomedical systems, and the conditions recognized may be a refl ection of values and assumptions rather than evidence of pathology. What is considered pathological and a disease is established by cultural and social conventions, even if they are called by medical and scientifi c terms. The role of cultural values in determining what is considered a disease was illustrated above in ”Biocultural Interactions: Depersonaliza- tion and Depression from Yogic Perspectives” and in the following consideration of pica or geophagy—dirt-eating—where what is considered a disease in biomedicine is seen as a healing practice in many cultures.
Social Construction of Disease
Engel’s biopsychosocial model (1977, 1980), which views sociocultural conditions as affecting disease through the mediation of risks such as exposures to diseases or other con- ditions that cause health problems (such as contamination) is extended in constructivist perspectives. These perspectives view the conditions in a culture as producing health problems as well as constructing how its members think about disease and its implica- tions, and consequently, how they experience health maladies.
Constructivist perspectives emphasize cultural infl uences, including social relationships, as fundamental in the causation of biological disorders. For example, politics produces
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disease through decisions that allow the creation of environmental conditions, such as pollu- tion or toxic waste sites, and the distribution of their risks. The risk of cancer is increased by governmental policies that allow cancer-causing pesticides to be used in agricultural fi elds or companies to discharge toxic chemicals into waterways. Social determination of disease occurs through political decisions that affect the availability of prevention services and treatment, such as when funding for preschool nutrition programs is cut, increasing nutrition- related disorders among poor children. Stress produced by social conditions reduces resis- tance to disease, or even produces disease, as when extensive work demands increased blood pressure and levels of hormones that compromise the immune system. Constructivist perspectives place the social dimensions of disease at the principal focus of the inquiry, as described earlier in the discussions of cardiac arrest, depression, and mental retardation.
Different constructions regarding the causes of maladies refl ect the power of cultural in- stitutions to select specifi c worldviews to explaining diseases. For instance, do poor people
Genital Cutting: Surgery or Mutilation?
Although it is assumed that medical practice is based on scientifi cally established procedures, there are many exceptions (e.g., lower back surgery, cesarean section, and circumcision). Is having a penile sheath, provided by our genetic code, a “disease” that requires medical treat- ment? It would seem so today, given the volume of circumcisions performed in the United States. Wallerstein (1980) argues, however, that male circumcision is without medical justifi - cation; his points were later extended in examinations of genital mutilations in cross-cultural contexts (Denniston and Milos, 1997). Although female genital mutilation has received the most attention, male circumcision is the most frequently performed and medically unneces- sary surgery. A deep cultural bias is illustrated in the use of “mutilation” to refer to cutting female genitalia but not male genitalia.
The historical introduction of male circumcision into the United States (during the nineteenth century) was as a cure for masturbation, immoral behavior and STDs, epilepsy, and cancer. Other arguments such as hygiene have been subsequently proposed, but the health risks of circumcision are considerable and have not been shown to outweigh any presumed advantages. Nonetheless, male circumcision remains a prominent feature of contemporary neonatal care (about 70 percent in this country) and a focus in public health and STD campaigns. Current arguments for adopting circumcision are often with no more justifi cation in medical science than were its original uses for curbing masturbation. The persistence of an unnecessary surgery can be attributed in part to having been integrated into mainstream American culture as well as the economic benefi ts that physicians receive. The persistence of American opposition to female genital mutilation while ignoring the dynamics of male genital mutilation is increasingly noted by other cultures as a form of gross ethnocentrism. Anthropologists and medical researchers have begun to turn their atten- tion to this medical practice that has little or no justifi cation in science or culture and that has broad but generally unassessed negative health consequences for men (e.g., see Goldman, 1997 ) .
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suffer from higher rates of lead poisoning because they are ignorant about such risks or do not care? Or does their higher risk refl ect the infl uences of a capitalist society where impov- erished people are more likely to have access restricted to old housing with contaminated paint and plumbing? Do higher levels of toxins in the bodies of inner-city children refl ect their parents’ neglect or the consequences of business and civic leaders that allow the opera- tion of highly polluting industries in these locations? These different perspectives produce different kinds of approaches to these conditions, one based on blaming the poor for their problems and the other attributing responsibility to broader societal factors, even the crimi- nal neglect by industrialists who cause diseased conditions by polluting the environments.
Constructivist perspectives emphasize that social concepts are more fundamental than biological conditions, that physical effects are produced, mediated, and experienced through human activities and cultural responses. Maladies, including disease, are pro- duced through social relations and in a cultural context that creates risks and the values that frame the experiences and give meanings to maladies. This is not to exclude biology as a causal or contributory factor but to recognize that social context is part of the causa- tion of health problems and that cultural belief and resources not only create the experi- ence and outcome of the conditions but may actually create conditions through beliefs.
The constructivist perspectives reframe the fundamental issue of diagnosing health problems as a discourse that involves ideological constructions, concepts based on cul- tural ideas regarding which aspects of health problems are most signifi cant in a society.
Cultural ideas are central, even in the formulation of biomedical diagnoses and the con- ceptualization of conditions that need to be treated, as discussed in the special feature
“Culture and Health: Genital Cutting: Surgery or Mutilation?”
Diagnoses as Construction
The social construction approach differs from biomedicine’s model of generic diseases in emphasizing that cultural processes create the systems within which maladies are defi ned and produced. Constructivist approaches illustrate that physicians’ diagnostic activities selectively predefi ne relevant symptoms out of a variety of vague conditions presented by patients. Patients express symptoms, which refer to their subjective assessment of their condition based on their experience of some unwanted conditions. A physician may derive important ideas from a patient’s expression of symptoms but is actually looking for signs of disease, what are considered objective data derived from laboratory tests, x-ray exams and other diagnostic procedures, indications revealed by physical examination, and past episodes revealed by the medical history. Physicians may depend on the patient’s expressed symptoms to formulate the diagnosis but tend to rely primarily on the signs provided by test results to “fi t” a patient’s condition within standard diagnostic categories.
Medical diagnosis is a social labeling process whereby individuals are given disease labels that only partially encompass their experience of a malady. For instance, you may complain about fever, a sense of fatigue, bodily aches, coughing, sneezing, and diarrhea, and your physician diagnoses that you have the fl u. Sneezing and diarrhea are not fl u symptoms, however, and may be ignored in your treatment. For both doctor and patient, social factors affect which symptoms and conditions are selected as relevant. This refl ects general cultural norms of what is appropriate (e.g., ignoring habitual back pain if you are a physical laborer or sexual symptoms when complaining about a general sense of “dis-ease”).
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Differences in diagnoses given to patients occur even when physicians use the same objective criteria as guidelines (Helman, 2001). As reported by Helman, British physi- cians were more likely to diagnose manic-depressive psychosis whereas American phy- sicians were more likely to note apathy and paranoia in the same patients and diagnose schizophrenia. Hospital staffs in both countries were more likely than research staff to diagnose schizophrenia. Doctors from different cultures come up with different diagno- ses because of cultural infl uences on what is considered most signifi cant.
The underlying assumptions of diagnostic processes are generally not subject to critical questioning and refl ection but, rather, are a part of the taken-for-granted assumptions of med- icine (Mishler, 1981). Doctors tend to think that they are actually discovering a disease rather than coming up with a culturally relevant classifi cation. Consequently, there is little consid- eration of what diagnosis involves or actually means because it would involve questioning the whole enterprise of medicine. Problems are recognized in the accuracy of diagnoses, but assumptions of universal generic diseases allow physicians to overlook the uncertainty and ambiguity in their efforts to determine the essential underlying features. The assumption is that the disease is real and that problems in diagnosis refl ect a lack of accurate knowledge, rather than unjustifi ed assumptions. To clarify the diagnosis of disease, physicians attempt to isolate what are considered biological features from the social context. But disease is socially constructed, with its consequences in part derived from the social context.
Constructivist approaches illustrate how diagnostic criteria are applied in relation to cultural and institutional factors, as discussed in the diagnosis of mental retardation. Con- structivist perspectives portray biomedical knowledge as the product of a particular cul- tural history and not a permanent empirical reality, as illustrated in the changing criteria used in the DSM.
Rather than merely accepting epidemiological fi ndings about different rates of dis- ease, or prevalence , in specifi c ethnic groups, constructivist approaches examine these fi ndings to ascertain how health care institutions operate. The relationships of ethnic vari- ables to health statistics may not refl ect the actual prevalence of disease. Instead, they may refl ect ways in which
Social and economic conditions determine who seeks care for disease and illness: for example, poor people who do not seek care for back pain caused by work conditions Cultural factors affect what is perceived as a condition requiring treatment: for exam- ple, cultures in which obesity is considered normal or parasitic disease is endemic Patients’ symptoms are selected by providers in formulating a diagnosis that provides epidemiological data: for example, fl u diagnoses rather than gastrointestinal disorders Culture dictates preferences for certain appearances: for example, where a drug over- dose or suicide is categorized as an accident
A patient’s malady is an interpretation within a system of cultural meanings and pri- orities, making cultural processes central to diagnosis. The social constructivist approach regards diagnoses as data for analysis, rather than objective decisions, as illustrated in a physician diagnosing a viral fl u and prescribing ineffective antibiotics for what is more likely an undiagnosed bacterial infection.
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Confusing Disease in “the Flu”
Differences between biomedical concepts of disease and people’s concepts of their maladies have important implications for clinical practice and epidemiology , the study of factors predicting the distribution patterns of diseases. In her role as a public health investigator, McCombie (1987, 1999) found that popular views of fl u affect the diagnosis and treatment. Infl uenza (fl u) has symptoms and causes distinct from popular conceptions of fl u. These differences detrimentally infl uence physicians’ judgment, practice, treatment, and consequently, epidemiological studies of the sources and causes of diseases. The biomedical conception of fl u refers to a respiratory tract infection caused by viruses, particularly of the Orthomyxoviridae family, and occurring with sud- den onset during the late fall and early winter. This viral syndrome produces symptoms of fever, chills, and headache, along with sore throat, congestion, and general bodily pain. Antibiotics do not affect viruses and are not an appropriate treatment for viral conditions.
What the general public often calls “fl u” involves symptoms indicative of gastrointestinal conditions: diarrhea, nausea, and vomiting. In McCombie’s (1987) study of people who contacted public health offi ces seeking advice for the treatment of fl u, only about 15 percent reported symptoms characteristic of infl uenza whereas more than 80 percent reported gastroin- testinal symptoms not characteristic of fl u. McCombie found more callers complaining about so-called fl u during periods when infl uenza was absent. These popular health beliefs about fl u present problems for epidemiologists because when people conclude they have the fl u, they generally deny the possibility that their condition has anything to do with food contamination.
This can result in infectious gastrointestinal conditions going unreported and untreated, obstruct- ing efforts to investigate food-borne diseases because people affected refuse to cooperate in investigations of probable food sources of their illness. If someone got sick after visiting their grandmother’s house, they might be offended if an investigator’s questions about what they ate suggested that grandmother had less-than-hygienic food preparation practices.
Physicians succumb to the labeling demands, using “viral syndrome” as the initial diag- nosis for likely bacterial diseases. McCombie noted that physicians often diagnosed viral syn- drome without confi rming laboratory tests and even in cases of doubt about a patient’s actual condition. This can present serious consequences for a patient because when bacterial diseases are misdiagnosed as viral fl u, no treatment may be provided for bacterial disease.
Physicians may also accommodate embarrassments about the causes of gastrointestinal prob- lems, failing to communicate to patients that their infection was transmitted by a fecal-oral route. This can contribute to further infection of others because of the failure to adopt appro- priate hygiene. Or physicians may prescribe antibiotics for a diagnosis of viral syndrome because patients demand antibiotic treatments, contributing to antibiotic-resistant infections.
McCombie suggests that people’s self-diagnosis of fl u plays important functions in American society, providing socially acceptable excuses that enable people to avoid reporting more socially embarrassing conditions (diarrhea, hangovers, or menses). Illness diagnoses may be more socially acceptable than disease classifi cations.
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