Social Health Biomedicine, the science-based ethnomedical system practiced in the United States, recognizes the impact physical health and mental health have on one another: when one falters, the other does as well. There is an increasing awareness in biomedicine of a third type of health, social health, which has long been recognized by many ethnomedical systems around the world. Each of the theoretical approaches to medical anthropology demonstrates that to develop a holistic understanding of human well-being, it is necessary to include mental, physical, and social health. Social health is driven by a complex set of sociocultural factors that impact an individual or community’s wellness. At a macro level, it includes the cultural and political-economic forces shaping the health of individuals and communities. An individual’s social health also includes the support a person receives from their extended social network, as well as the social pressures or stigma a person may face and the meaning that they ascribe to their experiences. Just as mental and physical health strongly influence one another, when a person’s social health falters, their physical and/or mental health declines as well. Figure 17.7 A person’s overall health is informed by their physical health, their mental health, and their social health. When one falters, the others are affected. (credit: Copyright Rice University, OpenStax, under CC BY 4.0 license) Physical environments—whether they are natural, constructed, or modified environments—shape cultural adaptations and behaviors. People living on islands and people living in deserts inhabit very different environments that inform their cultures and affect their biology. On the other hand, culture often affects how humans interact with their environments. People who work in offices in Los Angeles and hunter-gatherers in the Amazon River basin interact with their environments differently, relying upon very different subsistence patterns and sets of material culture. Culture also informs human biology. Eating a lot of spicy foods changes a person’s biophysiology and health outcomes, as do dietary taboos such as refusing to eat pork. These dietary choices inform biology over generations as well as within a single lifetime. The Biocultural Approach The biocultural approach to anthropology acknowledges the links between culture and biology. Biology has informed human development and evolution, including the adaptations that have made culture, language, and social living possible. Culture, in turn, informs choices that can affect our biology. The biocultural approach analyzes the interaction between culture, biology, and health. It focuses on how the environment affects us, and the connections between biological adaptations and sociocultural ones. The biocultural approach draws on biometric and ethnographic data to understand how culture impacts health. The effects of environment on biology and culture are apparent in the treatment of survivors of the Fukushima Daiichi nuclear accident that occurred in 2011 in Japan. Studies regarding the genetic health of survivors focus on the combination of environmental damage and social stigma in Japan due to their potential exposure to radiation. Symbolic Approach Other theoretical approaches ask different types of questions. What does it mean to be a patient? What are the social expectations for the behaviors of a person diagnosed as suffering from a particular sickness? Why is it symbolically meaningful for a treatment to be prescribed by a medical doctor? These are questions typically asked by those utilizing a symbolic approach to medical anthropology. The symbolic approach focuses on the symbolic thinking and beliefs of a culture and how those beliefs affect social and especially health outcomes. A person’s beliefs affect how they perceive treatments and how they experience illness. The most obvious example of the symbolic approach at work is the placebo effect. If a person believes that a treatment will be effective, this belief will affect their health outcome. Often in medical trials, people who believe they are receiving a treatment but are in fact receiving a placebo, such as a sugar pill, will demonstrate physiological responses similar to those receiving an active substance. Accounting for the placebo effect is an important consideration for all medical studies. The opposite of the placebo effect, the nocebo effect, occurs when a person believes they are not receiving an effective medicine or that a treatment is harmful. Common to both phenomena is the importance of meaning-centered responses to health outcomes. One of the most potent examples of this is voodoo death, when psychosomatic effects—that is, physical effects created by social, cultural, and behavioral factors—such as fear brought on by culture and environment cause sudden death. Related to the symbolic approach of medical anthropology is the symbolic interaction approach to health utilized by medical sociologists. Both approaches recognize that health and illness are socially constructed concepts. The symbolic interaction approach to health focuses on the roles of the patient, caregiver, and health care provider and the interactions that take place between people occupying these roles. Medical Ecology Another major medical anthropology theory is medical ecology. Pioneered by Paul Baker and based on his work in the Andes and American Samoa in the 1960s and 1970s, medical ecology is a multidisciplinary approach that studies the effects of environment on health outcomes. Examples of these environmental influences include food sources, environmental disasters and damage, and how environmentally informed lifestyles affect health. Whereas the biocultural approach looks at the intersection of biology and culture, medical ecology focuses instead on how environment informs both health and the culture surrounding it. A popular example of these connections can be observed in what are termed Blue Zones, certain locations around the world where a significant number of people regularly live exceptionally long lives, many over a century. These communities can be found in the United States, Japan, Columbia, Italy, and Greece. Common links between people who live in these places include a high-vegetable, low-animal-product diet (eggs and fish are the exception), a lively social life and regular activity, and a strong sense of cultural identity. A negative example of the links between environment and health can be viewed in the Flint, Michigan, water crisis. In this case, pollution of the city water system negatively affected health outcomes due to high exposure to lead and Legionnaires’ disease. Studies, including a long-term study by the National Institutes of Health, confirm that the water, central to the larger environment of Flint, negatively affected citizens of all ages, with particular harm caused to children and the elderly. Figure 17.8 Okinawa is classified as a Blue Zone, indicating that there is a high concentration of people near or over 100 years old living there. The long lives of Okinawans demonstrate the contributions of diet and lifestyle to health. (Credit: “Sata angagi” by Hajime NAKANO/flickr, CC BY 2.0) Cultural Systems Model Culture is a chief consideration in another theory, the cultural systems model. Cross-cultural comparison is a core methodology for anthropology at large, and the cultural systems model is ideal for cross-cultural comparison of health systems and health outcomes. Cultures are made of various systems, which are informed by sociocultural, political-economic, and historical considerations. These systems can include health care systems, religious institutions and spiritual entities, economic organizations, and political and cultural groupings, among many others. Different cultures prioritize different systems and place greater or less value on different aspects of their culture and society. The cultural systems model analyzes the ways in which different cultures give preference to certain types of medical knowledge over others. And, using the cultural systems model, different cultures can be compared to one another. An example of the cultural systems model at work is Tsipy Ivry’s Embodying Culture: Pregnancy in Japan and Israel (2009), which examines pregnancy and birth in Israel and Japan. A particular focus is how state-controlled regulation of pregnancy and cultural attitudes about pregnancy affect women differently in each society. Despite both societies having socialized medicine, each prioritizes the treatment of pregnant women and the infant differently. In the Israeli cultural model for pregnancy, life begins at a child’s first breath, which is when a woman becomes a mother. Ivry describes a cultural model that is deeply impacted by anxiety regarding fetal medical conditions that are deemed outside the mother’s and doctor’s control. As every pregnancy is treated as high risk, personhood and attachment are delayed until birth. The state of Israel is concerned with creating a safe and healthy gene pool and seeks to eliminate genes that may be harmful to offspring; thus, the national health care system pressures women to undergo extensive diagnostic testing and terminate pregnancies that pass on genes that are linked to disorders like Tay-Sachs disease. Japan, facing decreasing birthrates, pressures women to maximize health outcomes and forgo their own desires for the sake of the national birth rate. The cultural model for pregnancy in Japan emphasizes the importance of the mother’s body as a fetal environment. From conception, it is a mother’s responsibility to create a perfect environment for her child to grow. Mothers closely monitor their bodies, food intake, weight gain, and stressful interactions. In Japan, working during pregnancy is strongly discouraged. Ivry noted that many women even quit work in preparation for becoming pregnant, whereas in Israel mothers work right up to delivery. The cultural systems model also allows medical anthropologists to study how medical systems evolve when they come into contact with different cultures. An examination of the treatment of mental illness is a good way of highlighting this. While in the United States mental illness is treated with clinical therapy and pharmaceutical drugs, other countries treat mental illness differently. In Thailand, schizophrenia and gender dysmorphia are understood in the framework of culture. Instead of stigmatizing these conditions as illnesses, they are understood as gifts that serve much-needed roles in society. Conversely, in Japan, where psychological diagnoses have become mainstream in the last few decades and pharmaceutical treatment is more prominent than it once was, psychological treatment is stigmatized. Junko Kitanaka’s work on depression in Japan highlights how people with depression are expected to suffer privately and in silence. She links this socially enforced silence to Japan’s high stress rates and high suicide rates (2015). The cultural systems model offers an effective way to evaluate these three approaches toward mental illness, giving a basis of comparison between the United States, Thailand, and Japan. Assigning ethnomedicine the same value as biomedicine rather than giving one primacy over the other, this important comparative model is central to the theoretical outlook of many medical anthropologists. Figure 17.9 A sign outside of Aokigahara Forest asks people to reconsider taking their own lives. This public health initiative targets the cultural tradition of people dying by suicide in the Aokigahara Forest. (Credit: “Aokigahara (suicide forest) + very tired Liz” by Liz Mc/flickr, CC BY 2.0) The cultural systems model encompasses a myriad of cross-disciplinary techniques and theories. In many cultures, certain phrases, actions, or displays, such as clothing or amulets, are recognized as communicating a level of distress to the larger community. Examples include the practices of hanging “the evil eye” in Greece and tying a yellow ribbon around an oak tree during World War II in the United States. These practices are termed idioms of distress, indirect ways of expressing distress within a certain cultural context. A more psychologically driven consideration is the cause of people’s behaviors, known as causal attributions. Causal attributions focus on both personal and situational causes of unexpected behaviors. A causal attribution for unusual behavior such as wandering the streets haplessly could be spirit possession within the context of Haitian Vodou, while in the United States behaviors such as sneezing and blowing one’s nose might be attributed to someone not taking care of themselves. Causal attributions can be important to one’s own illness. Anthropologist and psychiatrist Arthur Kleinman has concluded that if doctors and caregivers were to ask their patients what they think is wrong with them, these explanations might provide valuable information on treatment decisions. One patient might think that their epilepsy is caused by a spirit possession. Another might suggest that their developing diabetes in inevitable because of their culture and diet. These beliefs and explanations can guide a doctor to develop effective and appropriate treatments. The approach recommended by Kleinman is known as the explanatory model. The explanatory model encourages health care providers to ask probing questions of the patient to better understand their culture, their worldview, and their understanding of their own health. Figure 17.10 The Tuskegee syphilis experiment ran for 40 years, studying untreated syphilis in Black men who believed they were receiving treatment for other illnesses. (credit: National Archives Atlanta, GA (US government)/Wikimedia Commons, Public Domain) Political Economic Medical Anthropology Another medical anthropology approach is critical medical anthropology (CMA), which is sometimes referred to as political economic medical anthropology (PEMA). Critical medical anthropology has a specific interest in the inequalities of health outcomes caused by political and economic hierarchies. Critical medical anthropology advocates for community involvement and health care advocacy as ethical obligations. Defining biomedicine as capitalist medicine, this approach is critical of the social conditions that cause disease and health inequalities and of biomedicine’s role in perpetuating these systemic inequalities. CMA is also interested in the medicalization of social distress, a process that has led to a wide range of social problems and life circumstances being treated as medical problems under the purview of biomedicine. Systemic racism and structural violence create many negative health outcomes. Structural violence refers to the way in which social institutions, intentionally or otherwise, harm members of some groups within the larger society. Structural violence can affect things such as life expectancy, disability, or pregnancy outcomes and can lead to distrust of medical systems. The Tuskegee syphilis study, a decades-long “experiment” that studied the long-term effects of syphilis in Black men under the guise of medical treatment, is a prime example of structural violence at work within the United States medical system. Black men involved in the study were not told they had syphilis and were denied medical treatment for decades, with most dying of the disease. The government’s internal mechanisms for halting unethical studies failed to stop this experiment. It was only when public awareness of what was happening resulted in an outcry against the study that the experiments were stopped. Another area of interest to medical anthropologists working with a CMA approach is how medical systems might be inherently biased toward or against certain segments of society. The research of anthropologist Leith Mullings demonstrated a lifelong focus on structures of inequality and resistance. Her work in Ghana examined traditional medicine and religious practice through a postcolonial lens, which was critical of the colonial legacy of structural inequality she observed. Her work in the United States also focused on health inequalities, with a special interest in the intersection of race, class, and gender for Black women in urban areas. It has been documented that some doctors in the United States regularly ignore the pain of women, and this is especially true in cases where the doctor displays racial bias. This tendency has been cited in several studies, including a study in The New England Journal of Medicine that found that women are more likely to be misdiagnosed for coronary heart disease based on the symptoms they give and pain levels reported (Nubel 2000). Another study in the Journal of Pain found that women on average reported pain 20 percent more of the time than men and at a higher intensity (Ruau et al. 2012). Another example of research that takes a CMA approach is Khiara Bridges’s 2011 Reproducing Race, which brings a critical lens to pregnancy as a site of racialization through her ethnography of a large New York City hospital. This medical racism contributes to the higher rates of African American infant and maternal mortality. Merrill Singer has done work on the role of social inequalities in drug addiction and in cycles of violence. This work has led to his development of the concept of syndemics, the social intersection of health comorbidities, or two health conditions that often occur together. For example, Japan’s hibakusha, or atomic bomb survivors of Hiroshima and Nagasaki, do not live as long as Japan’s normally long-lived population and are more likely to develop multiple types of cancer and other diseases tied to their exposure to nuclear radiation. In addition to these health risks, they face heavy discrimination from the larger Japanese population due to misinformation regarding nuclear radiation and radiation contamination. This discrimination carries over to the descendants of hibakusha, who have a higher rate of cancer than the average Japanese population despite having no detectable genetic damage from the atomic bombings. Studies are ongoing as to the cultural, economic, and genetic causes of this cancer. Syndemics is highlighted in the near-century-long struggle for numerous conditions caused by the atomic bombings to be recognized as related to the atomic bombings and thus treated by the Japanese government. Critical theories of health are an applied method, analyzing medical systems and applying critical theory, often with the goal of improving the system or improving policy. Recommendations for improvements often come out of research but may also be the starting point of a research project, as part of a data-finding mission to highlight disparity in health outcomes. Whether it is systemic racism in biomedical treatment or power discrepancies in ethnomedical rituals, critical theories of health are a key part of exploring medicine in action and understanding real medical consequences. From birth to the grave, social inequalities shape health outcomes, life expectancy, and unnecessary human suffering. Critical medical anthropology scholarship demonstrates the social forces shaping disease and health, from drug addiction to the impacts of climate change. This work becomes a self-evident call of action. It is medical anthropology in action. Profiles in Anthropology Angela Garcia 1971- Personal History: Angela Garcia comes from a small town along the Mexican border with New Mexico. She credits her background and upbringing with inspiring much of her later work in anthropology. Her early experiences have led her to focus on places where political and cultural spheres combine, resulting in inequality and violence. Within this framework, she has focused on medicine, postcolonial theory, and feminism. She first attended the University of California, Berkeley, and then earned a PhD from Harvard University in 2007, shortly thereafter publishing her first book, The Pastoral Clinic: Addiction and Dispossession along the Rio Grande. Area of Anthropology: medical anthropology, feminist anthropology Accomplishments in the Field: The Pastoral Clinic analyzes heroin addiction among Hispanic populations in New Mexico’s Rio Grande region. Garcia’s work focuses on the political and social realities that contribute to addiction and treatment, with dispossession as a central theme. The degradation of the surrounding environment and the economic decline of the Great Recession have been important factors in determining people’s life choices. Also influential has been a political reality that denies many participation or power. Garcia describes addiction as a recurring reality in the lives of many, leading them in and out of rehab in an endless cycle. Garcia also describes the damaging effects of addiction on relationships within families and communities. Garcia joined the Department of Anthropology at Stanford University in 2016. Her work has shifted to Mexico City, where she studies coercive rehabilitation centers run by the poor. She is particularly interested in political and criminal violence and in how informal centers like these exemplify the political and social climate within the larger Mexican nation. As much as these centers embody these realities, they also try to shift power away from pathways that lead to and encourage violence. In addition to this work, Garcia has also started examining addiction and mental illness in both Mexico and the United States Latinx (Latina/o) population. Importance of Their Work: Garcia publishes and presents frequently in preparation for books she is currently writing. Her work is crucial to understanding dispossession and power dynamics within the United States and Mexico, including how immigration and migration affect access to health care and shape identity.