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Cross -cultural Medicine

Multi pe Causality: Consequences


for Medical Practice
CORINNE N. NYDEGGER, PhD, San Francisco
When a scientifically trained health professional is called upon to deal with patients
holding differing causal views of illness, the resulting lack of communication is frustrat-
ing to both. This discussion traces some implications for medical practice of significant
cultural differences in two aspects of causal paradigms of illness: (1) terms accepted and
(2) dimension or level of causality typically sought. The second is the more pervasive
and intractable problem, having distinctive consequences for the role of curer, symp-
tomatology, diagnosis and treatment.

M odern medical scientists are apt to be ethnocen- considered appropriate in explanations, and the levels
tric about causality, assuming that questions and of cause appropriately addressed.10-18 Obviously, what
statements about causes have only one meaning which is appropriate is the content on which logic operates,
is self-evident and general. This is not the case. Causal not its structure. Nevertheless, such content differences
thinking is socially determined. That is, notions as to are fully capable, in themselves, of wreaking havoc in
what constitutes an adequate causal explanation are as medical practice.
rooted in the perspectives of each society as are its
ideas of right and wrong. Nor, as history shows, are Causal Paradigms
such notions fixed: ideologies and technologies change Questions about cause* are fundamental to human
through time and the meanings of "cause" change with thought. Work in cognitive development14"5 suggests
them.1'2 Closer to home, we find that causality is also that Kant correctly attributed the notion of cause to the
relative to disciplinary stance and to the nature of the structure of the human mind itself. Put simply, we are
problem at hand: like maps, "the sort of explanation unable to conceive of an event that has no cause. We
which is appropriate for one purpose is not appropriate may do no more than wonder what the cause might
for another."8 And even within our own medical tradi- be, but we are sure that there is one. Beyond this, the
tion, many issues in causal attribution remain problem- question of cause is no longer simple.
atic.4 To ask about cause is ambiguous and may include
The practice of medicine is dependent on a two-way any of a number of questions. The most basic and uni-
flow of information. Causal relativity is consequential versal are why (What is responsible? What is the pur-
for this process insofar as a physician's patients do not pose?) and how (In what manner did this event occur?).
share his scientific perspective.5 This is most obviously Throughout centuries of philosophical debate, causal
the case when patients are members of societies outside distinctions and classifications have multiplied, along
the Western tradition. But we need not go so far afield: with technical terms. To avoid misunderstanding, we
it is also true for many ethnic and even mainstream will follow the usage of anthropologists such as Peck"'
members of our own society.6'7 When a scientifically and Clark'7 and refer to the determination of final
trained health professional is called upon to deal with responsibility or purpose as ultimate cause (the why
a patient holding differing causal views, the resulting questions) and the mechanics of occurrence as immedi-
lack of communication is frustrating to both.8'9 ate cause (the how questions).
The problem is not one of divergent logics, for logical Although ultimate and immediate causes can be con-
processes are the same the world over. What differs are The author is indebted to Dr Otto Guttentag for his helpful comments
aspects of the causal paradigm: the elements (or terms) on various philosophical problems of causal analysis.

Refer to: Nydegger CN: Multiple causality: Consequences for medical practice (Cross-cultural Medicine). West J Med 1983 Mar; 138:430-436.
From the Medical Anthropology Program, University of California, San Francisco.
Reprint requests to Corinne N. Nydegger, PhD, Associate Professor, Medical Anthropology Program, University of California, San Francisco, San
Francisco, CA 94143.

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sidered different dimensions of causality, they also ap- ture can be assessed without the cognitive discomfort
pear as different levels of explanations sought. For ex- so apparent today.)
ample, do we accept a bacterial invasion as cause of The point is that all paradigms limit and shape reality.
an illness and seek no further? Or do we ask why the "Perception of what is believed to exist develops into
infection occurred? If we succeed in determining the existential propositions."20(p503) Reality is the consensus
circumstances of infection, do we go on to ask why of a group's learned perceptions-we never simply
those circumstances occurred? Do we ask about pur- "see it as it is." When dealing with alternative (that is,
pose? The questions can go on and on. The point at nonscientific) medical practices, little sense can be
which we stop, satisfied by the level of explanation made of them unless we make an effort to understand
reached, is primarily determined by the causal paradigm their underlying premises and models. Since excellent
we have learned to apply to this particular kind of analyses are available of an array of causal terms in
event. Within modern medicine, for example, one spe- paradigms other than our own,21-24 we will give only
cialty often begins its causal questions at the point one example to illustrate the medical consequences
where another stops (epidemiology and bacteriology, arising from the widespread concept of soul loss.
for example). Every paradigm, tacitly or explicitly,
targets a preferred level of causal explanation for spe- Soul Loss
cific classes of events, and in general places relatively In many cultures humans are assumed to have one
greater emphasis on ultimate or immediate cause. or more souls which can temporarily be lured or driven
The purpose here is to trace out some of the implica- out of the body with various consequences to health.
tions for medical practice of significant cultural differ- Among the Ilocano (Philippine rice-farmers) the soul
ences in both aspects of causal paradigms of illness: leaves the body under conditions of fear, shock or
(1) terms, largely immediate causes, that are accept- intense longing, as in homesickness. Children's souls,
able (viral infection versus demonic possession) and being less firmly seated than adults', are easily dislodged
(2) dimension or level of causality typically sought by even moderate stress levels.25 Soul loss causes
(immediate versus ultimate). The second is the more tremors, tics, dizziness, fainting, delirium and coma-
pervasive and intractable problem. interruptions of normal consciousness and control (the
Latin American ailment susto is felt to have a similar
Immediate Causes of Illness: The Question of How cause) .26
Every culture recognizes antecedent-consequent re- Soul loss occurs in a paradigm which includes de-
lations: the familiar "If X, then Y" But there are major tachable souls and a mechanism of mystic bonding to
cultural differences as to which Xs are permitted and place or person. This paradigm underlies all aspects of
which mechanisms are acceptable to relate X and Y. soul loss as a medical syndrome. For example, since
These terms and mechanisms are bound into models both patient and practitioner regard soul loss as a
which, at the same time, both explain and define reality. likely cause of a child's illness, they will focus on symp-
The scientific paradigm, for example, typically delimits toms of interrupted consciousness to the neglect of other
its reality to material terms and restricts causal relations symptoms such as fever, pallor and rigidity. This focus
to antecedents operating through measurable mecha- encourages the grouping of all loss of consciousness
nisms such as chemical reactions.18 symptoms into one diagnostic category, presumed to
As the history of science documents, discovery of have the common cause of soul loss. Due to the nature
new mechanisms may alter prevailing concepts of of this cause, the treatment indicated is to lure the soul
cause, hence the reality defined by the paradigm. Ex- back into the body by techniques that weaken the
planations of electricity and radioactivity, for example, mystic bonds.
each modified our concept of matter and expanded our Given the terms of the paradigm within which these
repertoire of causal mechanisms. And so our perspec- symptoms are perceived, both diagnosis and treatment
tives changed, by which we mean-in a literal sense- are appropriate and rational. Of course they are "mag-
that we see a different world. ical." So is our x-ray to an Ilocano villager. Magic is a
However, as Kuhn'9 showed, paradigms are in- contextually determined term and has little to do with
herently conservative. Faced with inexplicable data, the rationality, but has everything to do with conceptions
tendency is to reformulate them to fit, or to reject them of reality.27'28 We might define magic as a technology
outright. For example, claims of deaths by witchcraft based on another's reality.
and control of autonomic processes by yogis were initi- When two disparate versions of reality meet, con-
ally rejected because they could not be fitted into the fusion and miscommunication can be expected. A pa-
prevailing scientific paradigm. As new mechanisms were tient, certain his illness is soul loss, cannot understand
discovered and brought into the paradigm, states of the Western doctor's insistence on secondary symptoms
mind could be rephrased in these terms and the claims and irrelevant data. The doctor, pressing for full de-
accepted. (A current instance of this process is the scription of symptoms and background as his paradigm
scientific community's investigation of acupuncture. If requires, cannot understand the patient's reluctance to
an acceptable mechanism can be found-that is, one provide information. Diagnoses and recommended
which fits into our paradigm-the claims for acupunc- treatments made under these conditions are often re-
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MULTIPLE CAUSALITY

jected, to the doctor's bewilderment and annoyance. pose as cause is now attributed only to those things
Misunderstandings lead readily to mutual charges of that can be personalized, hence can have motives. Cur-
incompetence on the one hand and superstition on the rently, modern Western usage limits personalizing to
other, vitiating further attempts to provide and obtain animate things, primarily humans; therefore purposive
medical care. When the second paradigm difference- cause is also so limited.
dimensions of causality-enters the picture, difficulties In contrast, many other cultures allow more latitude
are multiplied. in personalizing their worlds; purpose as cause need
not be limited to humans. Therefore it is common for
Ultimate Cause of Illness: The Question of Why illness to be attributed to persons (witches, ghosts) or
The likelihood of a structural basis of causal thought personalized forces (gods, spirits) working by means
emphasizes the primacy of ultimate cause questions. A of various immediate causes. These mechanisms, how-
child's first question about cause is Why? And it is first ever, may be either supernatural or naturalistic.31'32
answered in purposive terms: it rains to make the However, it is easy to become distracted by this
flowers grow; the car moves to take us for a ride. issue. In itself, the attribution of personal motivation
Cause is ultimate purpose. However, the distinctive to forces we regard as inanimate is not necessarily con-
feature of modern science has been the extent of radical sequential. It is the level or type of cause typically
delimitation of causal paradigms to immediate causes. sought that is the more important determinant of the
Therefore a large part of growing up in our society is nature of a medical system. For example, although many
learning appropriate cause statements; that is, learning systems do assume the existence of purposeful agents,
to answer questions about cause by specifying chains this is not the case in a number of traditions that see
of immediate antecedent-consequent relations. Ulti- illness as the outcome of disturbances of equilibrium-
mate, purposive causes have been relegated to religion within the body, between body and soul or between
or philosophy as nonscientific issues. self and the social or spiritual order.9'33'34 In such sys-
Medically, this means that when a patient asks why tems, depersonalization is often the rule. Nevertheless,
he is ill, he receives an answer about how he became the search for ultimate causes of disequilibrium has had
ill. Since modern medicine has identified an impressive far-reaching consequences which have resulted in medi-
array of causal sequences, the scientist feels he has cal systems very different from our own.
provided a satisfactory answer. In contrast, most sys- Popular accounts have made us most familiar with
tems of medicine outside the Western tradition do not dramatic contrasts in treatment: chemotherapy versus
limit themselves to immediate antecedents, but go be- incantations, penicillin versus purgatives. But the search
yond them to deal explicitly with other aspects of for ultimate causes influences the entire system, from
cause.* Typically the emphasis is more often on ulti- professional training through diagnosis. The following
mate causes than on immediate. In such systems, the discussion will emphasize these less publicized, but even
manner in which an illness has developed is assuredly more consequential, influences.
of interest, but why it occurred is of paramount im-
portance.29,30 Medical Professionals
A scientist is likely to explain this difference of focus In some respects all professional curers (including
by lack of knowledge, the inability of other systems to Western physicians) are similar. On the curer's part,
accurately account for the causes of most ills. Accord- this role entails the apprehension of forces at work
ing to this line of reasoning, if naturalistic explanations that are obscure to laymen, intense and sustained efforts
of illness were understood, there would be no need to to cure ills, and high social status if successful. On
search for ultimate cause. This argument presumes that society's part, there is esteem mingled with fear of pos-
"scientific" answers are satisfying to the Western pa- sible misuse of special skills. In most systems other
tient and ultimate cause questions are no longer asked. than our own, the curer's role is distinctive because he
In fact this is by no means the case: patients continue also accepts determination of ultimate causes as a
to ask the purposive why? Modern medicine abjures the medical problem, thus as a necessary part of his job.
question, but it does not vanish when ignored. The Within such paradigms this is commonsense practicality:
answer is simply sought outside science. in cases of spirit-induced illness, for example, the im-
For years, a related and more exotic difference has portant question is not how this is accomplished, but
received the bulk of the attention-that of pe'rsonaliza- what is responsible. If this cause is not combatted, the
tion. Developmentalists have shown that the young patient cannot be permanently cured and will suffer
child's world is a personalized world wherein virtually attack after attack.
all objects are motivated, hence causes are predomi- Since causal agents are often spirits, forces of nature
nantly purposeful agents.'4 By maturity, personalizing or witches, the curer then must deal with potent and
has been reduced to socially acceptable levels and pur- dangerous forces in order to mediate between patients
and the sources of their ills. In addition to whatever
*Secular medicine (drugs, massage, ointments and the like) is well secular skills he possesses, his role demands supernor-
developed in most medical systems, but because it is directed primarily
toward simple symptom alleviation and unambiguous causes (exposure to mal power. Such power may be acquired in various ways,
cold, muscle strain), it will not be dealt with here. The interested reader
can find many references in Landy.23 depending on cultural rules and curer's specializations,
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but teaching alone is not enough. Power may be in- process of labeling any sense-perception, which involves
herited, be induced by drugs, trance or fasting, and be learned categories and learned criteria of inclusion.
even unbidden, imposed by spirits. However it may be That such categories differ from culture to culture is
acquired, the power is outside the normal and in the now well known. Although the spectrum, for example,
realm of the sacred.35 This distinction between curers is apparently perceived as such universally, the color
and lay specialists in secular practice is clear in the categories into which it is divided differ arbitrarily (that
following accounts of the source of the skills of two is, one group's blue may include another's green, and
Ilocano professionals: so forth). The aspect of labeling of importance here is
* Midwife (secular practitioner): its relation to paradigms. A simple example is the to-
Anyone can be a midwife if they have the patience to learn, mato: is it a fruit or a vegetable? Necessarily, the
though it is true some are better at it than others. I was taught answer is "it depends." It depends on the context of
by an old woman. . . . She helped me at first, but gradually I discourse and on higher level constructs of function,
did more and more. (C. N. Nydegger, PhD, unpublished data, which give meaning and specify the conditions under
1956).
which something is a fruit or vegetable.
* Curer (sacred practitioner): In this fashion, symptoms depend on constructs and
Pacifico ran home as if crazy, hitting anyone in his way. His
neighbors caught him and took him to his house where they paradigms of illness. Many factors enter into symptom
tied him, while he struck out and shouted. He continued like labeling. Simple frequency has been repeatedly docu-
this for some time, fighting with the not-humans: he was afraid mented as one such factor: some disorders are so
and did not want to accept the relationship. Finally he sur- ubiquitous that they become normal for these popula-
rendered to them and became normal again-for if you do not
give in they may cause your death-and he became a well- tions and those not so afflicted are seen as abnormal.*
known curer.36(P74) More subtle sociocultural factors have also been shown
to be important: health values, cultural emphases on
Because causal agents are often supernatural and a certain portions of the body, use of denial and so
curer's role is then analogous to a priest's, it has been on.6'41 The effects on this process of differing constructs
claimed that such medicine is confused with religion.29'37 and levels of causality in medical paradigms have been
But this is true only if we insist on our occupational neglected in this literature, yet they are basic and con-
boundaries. From a curer's perspective, he is practicing sequential.
medicine whatever we call it. It is interesting, in this We begin as children to learn to label specific sen-
regard, to note that when various shamanistic practices sations as symptoms: "I have a stomachache. I feel
were shown to have therapeutic value for mental illness, feverish." We also learn (albeit often incorrectly) which
we began to call these activities "curative" rather than symptoms are minor and can be dealt with at home and
"religious." In common with all cultural categories, which are serious and should be brought to a practi-
"medicine" and "doctor" are in the mind of the beholder. tioner's attention. Cultural models of illness select some
conditions as important, but not others. The selected
Symptoms conditions are gradually learned as symptoms. For ex-
Symptoms enter into a medical system at two levels: ample, Americans take temperatures because they have
a patient's use of symptoms to determine his need for learned that fever is a symptom, although they may not
medical attention, and a professional's use of symptoms know precisely of what. The Ilocano immediately
in diagnosis. Out of all the fluctuating physical sensa- label any swelling as a symptom (of probable witch-
tions and mental states that bombard the patient's con- craft), but fever may be ignored until it is extreme.
sciousness, he selects out only a few as signs of mal- When the medical paradigm emphasizes ultimate
function, of illness. How is this screening accomplished? cause, illness categories are more often defined in these
What criteria are employed? terms than by immediate cause or physical sensation
Overwhelmingly the criteria are cultural, learned in (witchcraft rather than inflammation, for example).
relation to specific paradigms of illness. This subject is Symptoms are therefore less often illness-specific42 and
difficult to discuss, for our terminology implies a good are of secondary importance to patient and curer alike.
deal more than is useful here. The phrase symptom A relative lack of interest in symptomatology is pro-
recognition is commonly used to refer to a patient's nounced in cultures like the Navajo, whose medical
awareness of a medically relevant condition. However, paradigm is an equilibrium model. For a Navajo pa-
recognition implies that a "real" symptom is present, tient, any persistent discomfort is a sign of discordance
of which the patient becomes aware. But the process and disequilibrium, be it depression, chest pains or
actually is that of creating a symptom by selecting aching joints. The presenting symptom commonly takes
out certain sense-perceptions which are then labeled the form "I feel bad all over." This is perfectly clear
"symptom." Selection occurs in relation to a specific to a Navajo diagnostician who initiates a search for
paradigm and is meaningful only in relation to that cause of the disturbance. Neither patient nor curer need
paradigm. With illness as with other troubles, "the pursue symptoms further.
effort to find and implement a remedy is critical to the In accordance with this causal paradigm, a Navajo
processes of organizing, identifying, and consolidating patient has been taught to discriminate only a crude
the trouble."s38(P122) *For example, Ackerknecht32 reports this for a skin disease in South
America, Wallace39 notes a similar acceptance of hallucinations and
Symptom labeling is no more than the familiar Clark40 reports ignoring of coughing, sweating and children's diarrhea.

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vocabulary of symptoms. Nor does he see the need for illness categories are less useful, for the curer is charged
further refinement, since the problem is ascertaining with determining ultimate causes. Although medical
why an imbalance has occurred; with a few exceptions, histories may limit possibilities, they are unequivocal
symptoms are irrelevant to this problem. However, a only in cases of flagrant transgression of taboos. Sec-
physician finds "feeling bad all over" an inadequate ond, instances of apparent causes masking deeper
description and cannot understand why his requests for causes are not uncommon; a diagnosis may be correct
further specificity are met with incomprehension. yet inadequate because it did not reach the ultimate
There is a two-way flow of influence between diag- cause. Third, diagnoses of witchcraft and taboo break-
nostic categories and symptom labeling. Contrary to ing often involve members of the patient's family or
textbook organization, our symptoms are shaped by community. A faulty diagnosis in these cases can be
our culture's diagnostic categories and by the causal more dangerous to curer than patient.
bases of our medical paradigm. When lay and profes- Fourth, if supernatural agency or witchcraft is sus-
sional paradigms are essentially the same, symptom pected, the sacred power of the curer is prerequisite for
labeling is similar; patient and practitioner speak the diagnosis itself. Only trance, divination-some beyond-
same medical language. But when paradigms differ, normal experience-can lead to correct causal attri-
miscommunication typically results even at this initial bution. Whether the curer's medical paradigm is
contact, setting the stage for further difficulties.43 elaborate8'44 or relatively simple,36'45 the majority of di-
agnostic decisions are based on contact with the sacred,30
Diagnosis always a source of potential danger to the curer. This
In all medical systems, treatment is determined by ingredient of diagnosis is emphasized in systems like
diagnosis. But when the system emphasizes ultimate that of the Navajo, who have placed diagnosis and treat-
causes, determination of the process (immediate cause) ment in the hands of different specialists. Treatment
is of secondary importance, if not irrelevant. In this skills involve ritualized contacts with supernaturals,
context, constellations of symptoms tend to be unre- which are taught during a lengthy apprenticeship. Diag-
liable diagnostic criteria. In the first place, symptoms nostic skill, on the contrary, is unteachable: it is an in-
are often ambiguous, pointing in many directions. Sec- herent ability to divine, merely refined by practice.
ond, the powers of the supernatural are broad: if such However accomplished, diagnosis is never idiosyn-
an agency is responsible, the same syndrome can take cratic or unsystematic. It too is shaped by the general
many guises. Third, even unambiguous ailments may cultural context and constrained by the medical para-
not provide causally diagnostic answers; for example, digm within which it occurs.46-48 The range of diagnoses
smallpox is often thought to be spread (caused in the for broad classes of illness is always limited and the
ultimate sense) by supernaturals.36 curer whose diagnoses deviate notably from this pattern
Background information is a major source of diag- is suspect. These diagnostic patterns may appear un-
nostic hints for all medical practitioners. But an in- systematic: sometimes they refer to the immediate
digenous medical history bears little resemblance to cause (such as soul loss), at other times to purposefully
that obtained by a physician, although it is a functional causal agents (witchcraft) and even to Western disease
equivalent. The latter's interests are in childhood ill- categories (smallpox). But underlying the apparent
nesses, symptom lists and the like-a narrow focus on confusion is a paradigm-related orderliness which be-
the patient himself. The indigenous curer is more often comes apparent when we focus on the question of ulti-
concerned with such things as breaking of taboos, work- mate cause-why rather than how.
ing in spirit-haunted places, bad relations between
neighbors-a broad picture of the patient in his social Treatment
context. The two kinds of histories converge mainly in "Hierarchies of resort" in curative practices have
determining sources of infection or poisoning when much in common the world over.34 495' In every society
questions of work and leisure habits, social contacts known, mild symptoms and common ailments are first
and movements are also pertinent within the scientific treated by home remedies. Poultices and potions are
paradigm. universal; heat treatments and massage are widespread,
Patients are accustomed to certain kinds of ques- as is prayer for supernatural intervention. Indigenous
tions, which make sense to them within their own lay medicine also has remedies to deal with minor ills
models of illness; they understand that they are diag- that have supernatural causes: charms, rituals, incan-
nostically relevant, though they may not know why. So tations and the like. Contrary to popular assumption,
we expect questions about our health history, but not not all supernaturally caused ills are grave or mysteri-
about dislike of our in-laws. The indigenous patient ous; they may often be diagnosed and cured by home
understands his curer's need to know where he has been remedies with no more fuss than we make over a cold.
cutting wood (to estimate probabilities of angering In a mild case of children's soul loss, for example,
wood spirits), but he is unlikely to see the point of simple incantations and object-manipulation can neu-
questions about a swelling-in-the-neck illness in child- tralize the bonding mechanism and lure back the soul.
hood. However, if lay medicine provides no relief, or if the
Diagnosis is even more difficult for indigenous curers symptoms are ambiguous, professional diagnosis and
than for our own professionals. First, symptoms and treatment are indicated. (These days, one of the pro-
434 THE WESTERN JOURNAL OF MEDICINE
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fessionals consulted is likely to be a Western physician. talk with the spirits" (C. N. Nydegger, PhD, unpub-
The conditions under which he or she is consulted have lished data, 1956). Since both deal merely with effi-
been studied in many societies.22'52-57) cient causes, they are scarcely worth distinguishing
The distinction between secular and professional from one another.
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