SUSAN M.

DIGIACOMO
Department of Anthropology
University of Massachusetts at Amherst

Can There Be a "Cultural Epidemiology"?

A brief excursion through the history of social medicine suggests that, at

least in principle, epidemiology and anthropology are natural allies in
the study of disease in human populations. In practice, however, this alli-
ance has been limited and remains problematic. This article examines the
possibilities for interdisciplinary research, taking cancer epidemiology
as a case in point. I argue, on the basis of participant-observation over a
period of nearly two years in the epidemiology department of a medical
research institute in Catalonia (Spain), that bioscientific uses of the con-
cept of culture have led, disappointingly, to its reification as "beliefs"
and its incorporation into the naturalist epistemology of Western institu-
tional medicine. The unfortunate consequence is the medicalization of
culture understood as "difference," which often stands in for social class.
[cancer, culture, epidemiology, epistemology, research methods]

E ven a brief excursion through the history of 19th-century social medicine

(Trostle 1986b) and 20th-century studies of the health consequences of so-
cial and cultural change (Trostle 1986a) suggests two things: (1) that bio-
logical and anthropological paradigms are not inherently incompatible; and (2) that
epidemiology and anthropology are natural allies in the study of disease in human
populations (see Dunn and Janes 1986). But ten years ago, the possibilities of such
an alliance remained less than fully realized, and, in fact, Trostle himself charac-
terized the relationship as one of "benign neglect" (1986a:80) and a series of
"missed opportunities" (1986a:79).
More recent assessments have been more optimistic, sometimes even trium-
phalistic. William True has suggested that epidemiology, with its propensity for
borrowing concepts from a wide range of disciplines and integrating them into its
research questions, may be "a way to carry out some of the holistic message of an-
thropology" (1990:317). More recently still, Hahn has argued that "the underlying
logics of anthropology and epidemiology have much in common and... that prac-
tices developed in each discipline are necessary complements to practices in the
other" (1995:99), and Agar (1996) eagerly looks forward to a conceptual synthesis
he sees as imminent, uniting a newly self-aware and reflexive epidemiology with

Medical Anthropology Quarterly 13(4):436-457. Copyright © 1999, American Anthropological Association.

• 436
CAN THERE BE A "CULTURAL EPIDEMIOLOGY"? 437

anthropology through the holistic, systemic, and synthetic concept of culture. A

decade after Trostle's initial assessment of the limited possibilities for collabora-
tive work, he and Johannes Sommerfeld, writing in the Annual Review of Anthro-
pology, concluded that the situation is no longer one of benign neglect, that the
foundation has been laid for a cultural epidemiology capable both of more appro-
priate and effective disease control and prevention, and of advancing theory in so-
cial analysis (1996).
A closer look, however, shows that this brave new world is not yet a reality
but a consummation devoutly to be wished. In his enthusiasm, Agar gets a little
ahead of himself, arguing that "epidemiology in recent times displays a self-aware-
ness, a reflexivity about its concepts and methods of study," but at the same time
acknowledging that something so basic as "an ethnographic examination of the so-
cial processes by which quantitative data are generated would be useful"
(1996:401). Trostle and Sommerfeld concede that "collaboration between anthro-
pology and epidemiology in the past decade has been uneven. Multimethod re-
search is increasingly undertaken, but theoretical challenges and conceptual cri-
tiques are still relatively uncommon," and they propose that more productive
exchanges may emerge as a consequence of "studies of 'anthropology in
epidemiology,' ethnographies (or even short reports) about collaborative or con-
tested sites" (1996:265-266).
The present article is one such study of collaboration and contest. I speak as
one who has spent nearly two years occupying a privileged, if also precarious, van-
tage point as the only anthropologist in a department of epidemiology in a univer-
sity-affiliated medical research institute in Barcelona, generally acknowledged to
be the premier location for epidemiological research in the Spanish state. The pres-
entation of some of my work on U.S. cancer survivors at the Spanish sociology
meetings in the fall of 1989 caught the attention of a Catalan epidemiologist doing
research on "diagnostic delay" in cancer treatment and its relationship to survival
rates. Our meeting led to an invitation to apply for a visiting professor position in
his department in the spring of 1992. Once there, I applied for, and received, a re-
search grant for 1993.
The institute has always had a close relationship with one of Barcelona's pub-
lic hospitals, and I lost little time in seeking out physicians there who were willing
not only to talk with me about their experience of diagnosing and treating cancer
patients, but also to allow me to observe their interactions with those patients. The
length of the interval between the onset of symptoms and the initiation of treatment
was a constant concern for these physicians, who frequently found themselves di-
agnosing advanced, widely disseminated malignancies with a poor prognosis. The
tightly controlled moral panic of doctors unable to offer effective treatment, and
the inarticulate, embodied anxiety of the patients were mirror images of each other
(see Roig 1991). The resoundingly meaningful silences that characterized doctor-
patient encounters compelled my interest as a cultural anthropologist, especially as
one whose own experience of cancer diagnosis in Barcelona, following a lengthy
self-imposed delay, had been so different (see DiGiacomo 1995). I had identified
an area of ambiguity and dissonance which might signal changes in the cultural
practices of both physicians and patients, and I thought that mapping these would
be my best contribution to the diagnostic delay project.
438 MEDICAL ANTHROPOLOGY QUARTERLY

I was trying to stimulate the reflexivity Agar claims to perceive in the emer-
gent "new epidemiology" by defamiliarizing and unpacking the concept of diag-
nostic delay—precisely the kind of "theoretical challenges and conceptual cri-
tiques" Trostle and Sommerfeld (1996:265) encourage—but my efforts were met
alternatively with indifference, or with resistance that bordered at times on hostil-
ity. To my surprise, at the end of my first appointment in 1992,1 was criticized for
failing to be a "team player," for showing too much independence by seeking con-
tact with physicians at the hospital, several of whom shared ongoing research inter-
ests with colleagues in various departments at the institute, including epidemiol-
ogy. Accordingly, one of the first things I did in early 1993 was audit a graduate
course in cancer epidemiology, the same one some of the master's-level students in
the department were taking for credit. When I offered to interview the subjects of a
study of the genetic markers of pancreatic cancer—patients who had already been
interviewed by other members of my research group about their dietary habits and
exposure to possible carcinogens—my suggestion was dismissed without explana-
tion. At the urging of the head of my research area, I produced a detailed proposal
for a jointly authored article exploring the variations of behavior and practice that
the concept of diagnostic delay obscures. To my puzzlement, he ignored it. He ac-
tively opposed a research project I designed jointly with a physician, also a faculty
member in another department at the institute, who had sought me out early in my
time there to talk with me about his own attempts to find new ways of communicat-
ing a diagnosis of cancer to his patients. An attempt was made to force me into the
position of coordinator of a vaguely conceived multicentric research project on
"cancer and culture" which would have involved widely divergent professional in-
terests (oncology, gerontology, family medicine, social work, epidemiology, and
clinical psychology) and patient populations. Following a meeting to discuss the
project, and with the help of a physician who had been present, I drafted a long
memorandum discussing the difficulties of using the concept of culture to bridge
so many different concerns in the context of a single project; again, no response
was forthcoming. Unable to find a way of participating in the diagnostic delay pro-
ject in a manner that did not also require alienating myself from my own profession
(see Bibeau 1997:247), I pursued related interests (changing media representations
of cancer) on my own and turned my attention increasingly to epidemiological
practice itself as I observed it daily in my department, both in my own research
group and in others.
Ultimately, I came to the conclusion that modern epidemiological research is
increasingly method-driven in a way that limits research problems to those that are
strictly quantifiable. This, in turn, has seriously distorting effects on the anthropo-
logical concept of culture as deployed in epidemiology. The present article is con-
ceived as the third in a series of four articles (see DiGiacomo 1995 and 1996 for the
first two), each of which holds up a different kind of analytic mirror to the prob-
lems I confronted.

Modern Epidemiology and Naturalist Epistemology

In a 1980 essay in the Annual Review of Public Health surveying the intellec-
tual terrain of epidemiology, Reuel Stallones offers the following programmatic
statement as the foundation for advancement in epidemiological research:
CAN THERE BE A "CULTURAL EPIDEMIOLOGY"? 439

Epidemiology represents therecognitionthat the patterns of occurrence of disease

and disability in human communities are determined by forces that can be identi-
fied and measured, that these forces include but are not limited to medical con-
cepts of etiology, and that modification of these forces is the most effective way to
prevent disease. This establishes a territory of especial beauty at the intersection
of the biomedical and social sciences—a subset of human ecology which is espe-
cially focused on human health and disease. [1980:80, emphasis added]
Stallones proposes this charter as an antidote to "a continuing concern for
methods, and especially the dissection ofriskassessment, that would do credit to a
Talmudic scholar and that threatens at times to bury all that is good and beautiful in
epidemiology under an avalanche of mathematical trivia and neologisms"
(1980:69-70). In the 1950s and 1960s, epidemiological studies of noninfectious
diseases revealed the substantial limitations of the one agent/one disease model of
causation, and interest in "webs of causation," in which several causes converge
upon an effect, began to develop (see Krieger 1994 for a detailed history and cri-
tique of this concept). This shift in the framing of epidemiological research prob-
lems entailed a methodological revolution whose beginnings Stallones traces to
the Framingham coronary heart disease study: the use of increasingly powerful
multiple-regression statistical models to measure the relative importance of asso-
ciations between variables—including those defined as social or cultural—and be-
tween clusters of variables and diseases.
However, the "background understandings" (Gordon 1988) that underlie as-
sumptions about measurement, knowledge, and truth, which Gordon, following
the philosopher Charles Taylor, calls "naturalism," have not been substantially al-
tered by this shift in the model of disease causation. I want to spend a little time de-
tailing these understandings because they have consequences for the ways in
which epidemiology borrows and operationalizes anthropological concepts—most
importantly, the concept of culture. This is a portrait, in broad strokes, of the sub-
jectivity of bioscience, drawn from Gordon's 1988 essay, 'Tenacious Assump-
tions in Western Medicine."
The priority of valid and reliable measurement (True 1990:313) is rooted in a
disposition to regard the universe as a mechanism endowed with an essential real-
ity prior to and autonomous from the meanings human subjectivity may project
upon it. Language depicts reality (more or less accurately, depending on the preci-
sion and regularity with which it designates its object; see Foucault 1975:113 and
Good 1994:9-10) but does not constitute it. "Real" knowledge penetrates the
workings of the mechanism by studying its parts—this is the scientific notion of
"variables"—in hierarchically ordered cause-and-effect relationships to each
other. While there are varying strata of complexity, the different levels may be
treated analytically as if they were of the same order (culture, for example, is as-
similated to DNA as a "code"). The best vehicle for expressing this knowledge is
the purely referential, objective language of numbers, and the sense that allows us
best to apprehend reality is vision, which enhances the separateness of the knower
from the object of knowledge.
This knower is, like the variables she studies, a distinct unit, logically prior to
society, which is, like all systems of relations, derivative, and a source of external
constraints and biases that limit the knower's ability to see things as they "really"
are. Detaching herself from everyday understandings, the knower also contrives a
440 MEDICAL ANTHROPOLOGY QUARTERLY

special context—the laboratory in experimental research, or cohort and case-con-

trol studies in epidemiological research—in which predictor, outcome, and con-
founding variables may be distinguished, measured, and analyzed.
Nor is this understanding of the individual knower limited to scientists. The
ideal modern identity, what Geertz described for Western cultures as "a bounded,
unique, more or less integrated motivational and cognitive universe, a dynamic
center of awareness, emotion, judgment, and action organized into a distinctive
whole" (1983:59), can be fully realized only when it is determined as little as possi-
ble by cultural values and social norms, free to be its own unique author, able to
disengage itself both from context and from its own subjectivity—in other words,
become an object to itself—and make rational choices. Self-knowledge and self-
control are potentially unlimited. It is within the terms of this cultural construct that
a person may be said to "possess" health—good or bad—and in which health be-
comes an individual responsibility and even a civic duty, a project for the self to
work on (Herzlich and Pierret 1987). Health education is, in Foucault's terms, a
discipline, a technology of the self (see Dreyfus and Rabinow 1983:174-175)
which produces that modern form of subjectivity, the healthy citizen (Gastaldo
1997).
The epidemiological "web of causation" model views disease incidence in
populations as the sum of individual cases of disease (Krieger 1994:892), thus re-
ducing the social to the individual. Biological individualism is reflected in and re-
produced by the epidemiologic framing of the social determinants of disease in
terms of naturalized and unproblematized "race, age, and sex" characteristics of
persons as individual bodies specifically located in time and place (Krieger
1994:898). As an applied science, epidemiology strives to provide information on
which successful medical interventions and disease prevention programs can be
based. Given the naturalist epistemology that underlies epidemiologic research,
prevention should be a relatively simple matter of accurately informing medical
professionals and the public about known risks to health. Once the real situation is
made known, enlightened self-interest should be sufficient to persuade people to
act rationally—for example, by bringing symptoms of serious disease to a physi-
cian's attention immediately—in order to preserve their health. Of course, things
are not as simple as this. We can begin to construct an explanation for why they are
not by looking at what happens to the epidemiological concept of risk when trans-
ferred to clinical medicine.

Epidemiologic Risk and Clinical Practice

Sandra Gifford's 1986 article "The Meaning of Lumps" explores the ambi-
guities of "risk" in relation to breast cancer. Epidemiologists have identified sev-
eral characteristics thought to be associated with increased risk of developing
breast cancer, including a history of benign breast lumps, commonly referred to as
fibrocystic breast disease. Many women experience alterations in their breasts in
the course of their menstrual cycle, and the distinction between normal change and
pathological change in any given case depends on the woman's age and the clini-
cian's level of concern and diagnostic expertise. Of course, any breast lump may be
cancerous unless a biopsy demonstrates it to be otherwise. Studies that show an in-
creased rate of breast cancer among women with fibrocystic breast disease are
CAN THERE BE A "CULTURAL EPIDEMIOLOGY"? 441

based on biopsy diagnosis, but biopsies tend to be reserved for women whose
medical histories include additional risk factors. Whatever the result of the biopsy,
a woman who has had one is more likely to get breast cancer simply because she is
in a higher-risk group to begin with. Yet despite these problems in establishing the
degree of cancer risk involved in benign breast disease, many physicians and their
patients continue to assume that a benign lump can cause, become, or mask breast
cancer.
Epidemiological statements about risk are statements about groups of people;
clinical medicine treats individuals. The clinical management of risk entails a shift
in meaning from statistical concept to physical entity: the physician "diagnoses"
risks, observing signs of possible future disease in the patient's body. We have all
become accustomed to hearing doctors warn us that we have X risk factors for heart
disease, osteoporosis, etc., and outline a treatment plan to reduce the risk factors
we can affect through our behavior. Yet, the uncertainty surrounding benign breast
disease causes the very idea of risk to spread at its boundaries, engulfing the physi-
cian as well as the patient. Recommending a biopsy is a more aggressive strategy
than suggesting a low-fat diet, and it protects the physician from the risk of a mal-
practice claim as a result of a delayed diagnosis of breast cancer (Katz et al.
1993:268) as much as it protects the patient from the consequences of what may be
a premalignant condition. An even more extreme solution to the problem of diag-
nostic uncertainty and possible malignancy is prophylactic mastectomy. Risk, un-
derstood as a sign of future disease, resides in the lumpy breast, and the surgeons
Gifford interviewed state quite clearly that, when they remove the breast, they are
removing the risk. In the 1990s, results are beginning to be reported for pilot
chemoprevention programs using tamoxifen, an anti-estrogenic agent sometimes
used in lieu of surgery to treat primary breast cancers and metastatic breast cancer,
to "treat" women whose sisters, mothers, or daughters have had breast cancer
(Powlesetal. 1990).
In the United States, many people live uneasily with the perception that their
well-being is constantly threatened by risks, against which we seek various forms
of insurance and for which we often seek to blame others when insurance fails.
This sense of pervasive risk is heightened for women who have received a clinical
diagnosis of risk for breast cancer. But theirs is neither the statistical risk of
epidemiology nor the objective risk of the clinician. It is risk internalized and trans-
formed into a feeling state, a subjective sense of probability that emerges out of the
interaction between personal values and broadly social perceptions about how
much uncertainty is tolerable. Talk of risk elicits talk of control, and the women
Gifford interviewed also spoke of feeling out of control. They have been thrust into
a liminal condition that is neither health—you cannot be both healthy and at risk at
the same time—nor illness. Again, the concept of risk spreads at its margins to in-
clude the risk of living a medicalized life indefinitely, perhaps permanently, and
losing control over the definition of one's own health.
Gifford points out that disease prevention, screening, and health promotion
efforts aimed at changing women's habits or "lifestyles" are based on epidemi-
ologic risk equated with the "objective" clinical risk of malignancy. This approach
elides the substantial qualitative differences among statistical, clinical, and lay
risk, all too often treating incommensurate concepts as if they were identical.
Standard explanations for the failure of prevention programs rest on identification
442 MEDICAL ANTHROPOLOGY QUARTERLY

of psychological and cultural "factors" that prevent the dissemination of informa-

tion to individuals at risk and/or inhibit (individual) understanding of its signifi-
cance (Gram and Slenker 1992). Social causes—for example, those having to do
with the structure of, and access to, the health care system—are less frequently in-
voked and often treated as secondary or even irrelevant (for example, see Burack et
al. 1993; for a critique, see Krieger 1994:892).
It is not difficult to detect naturalist epistemology at work here. Epidemio-
logical science is the source of "real," "true" knowledge of the risks—if not of the
cause(s)—associated with breast cancer. Screening programs and other efforts at
health promotion assume that epidemiological knowledge about risk can be trans-
ferred directly to the clinic, when in reality physicians who treat patients may be
hard pressed to find constructive ways to use this knowledge in their daily work.1
The well-documented failure of many attempts to introduce new health habits,
such as monthly breast self-examination and adherence to mammography screen-
ing programs, or "lifestyle" changes affecting diet and exercise, is often laid at the
doorstep of the individuals at whom they are aimed, who have responded in an
inappropriately emotional way to objective information (Lerman et al. 1993) or
simply failed to cooperate fully with medical recommendations (Marantz 1990).
Alternatively, individual physicians are blamed for failing to recommend mam-
mography screening to those patients who would be appropriate candidates for the
procedure (Burack et al. 1993:331).
I coincide with Gifford's (1986:217) insightful perception that behind con-
temporary multiple-causation epidemiologic models of risk there lurks a continu-
ing belief in, or wish for, the doctrine of specific etiology, and I would argue fur-
ther that the biological agent of disease has been joined in epidemiologic thought
by the cultural "germ" (Ots 1991:36). Now I would like to turn to an examination
of this cultural causal agent/risk factor in the work of my colleagues on the subject
of diagnostic delay as I observed it during 1992 and 1993 as a member of an
epidemiological research group working on—among other topics—diagnostic de-
lay in cancer treatment and its impact on survival times.

Culture as a "Risk Factor"

The legacy of John Cassel's work on the health effects of social and cultural
change had a significant influence on the thinking of the head of my research area,
who had received his M.P.H. at the Chapel Hill School of Public Health, where he
also was exposed to medical anthropology during Nancy Scheper-Hughes's tenure
in the Chapel Hill Department of Anthropology. As Trostle points out, social
epidemiology at Chapel Hill was distinguished from many other attempts at inter-
disciplinary collaboration in the 1950s and 1960s by the effort to develop anthro-
pologically and sociologically sophisticated theoretical models that could be tested
using epidemiological methods and applied in public health practice (1986a:79).
However, as Trostle also observes (1986a:68-69), although theories about the
nature and effects of social change became increasingly important in social epi-
demiology, studies such as the ones Cassel undertook in Appalachian communities
did not contribute to further theorizing in anthropology. These studies drew on the
concept of acculturation, which is premised on the assumption that, prior to contact
with the West, exotic cultures were stable, coherent, and genuine, unpolluted by
CAN THERE BE A "CULTURAL EPIDEMIOLOGY"? 443

exogenous influences and existing in harmony with a stable environment.2 In

short, cultural stability was represented as normal and cultural change as abnormal
(Anderson 1973:205). It is perhaps neither surprising nor unreasonable that epide-
miologists should have found this view so congenial. Most epidemiologists are
physicians by training (Frankenberg 1993:227), and medicine tends to view
change in the body as pathological. And the idea of culture as a fixed element per-
mitted epidemiologists to treat it as a constant in the laboratory sense, separately
from society, which was treated as the variable. Cassel sought "natural experi-
ments" in Appalachian towns, studying a group of "rural mountaineers who were
the first of their family to engage in industrial work" and postulating that the "in-
congruity between the demands of the social system and the culture they brought
with them . . . predicted . . . poorer health indexes" than those found among sec-
ond-generation factory workers "of the same ethnic stock and from the same
mountain coves" (1964:1486-1487). A second study on urbanization and death
rates from heart disease as a proportion of total deaths focused on "stable groups in
which the social situation had changed around them": "rural residents in North
Carolina living in counties with differing degrees of urban growth" (Cassel
1964:1487).

Diagnostic Delay and Cultural Risk Factors in Cancer Diagnosis and

Treatment
This view of culture as a closed and stable system persists in epidemiology
long after it was discarded in anthropology, precisely because it lends itself so well
to naturalist epistemology. In his contribution to the 1984 Proceedings of the
Twelfth Congress of Catalan-Speaking Physicians and Biologists, entitled "The
Process of Becoming 111," the head of my research area posed the following ques-
tions about the ethnographic study of pain:
Qualitatively speaking, a number of questions remain to be addressed: Which are
the most influential cultural factors? What do they affect: the perception of pain,
conveying pain, the sensation of pain, response to pain, or perhaps all of these?
Other questions can be formulated quantitatively: what proportion of cross-cul-
tural difference is accounted for by each cultural factor and by the culture as a
whole? What is the magnitude of these differences when we control for such fac-
tors as underlying pathology or individual psychophysiological characteristics?
How many of the differences attributed to culture could be due to such factors as
social class or the health care system? What distortions are introduced by the
methods and the personal characteristics of the observer? [Porta 1984:288;
author's translation; emphasis in original]
In this view, culture is reified as an ensemble of measurable "factors" with de-
terministic power over specific aspects of illness, in this case, pain. The subjectiv-
ity of ethnographic methods is seen here as an obstacle to be overcome, a source of
"bias" that casts doubt on the validity of the analysis. And the subjectivity of the
sufferer—the meaning of pain—is not even part of the catalogue.
This same approach to culture as a series of "factors" and this mistrust of sub-
jectivity were evident in the diagnostic delay project. The interval between the first
symptom (medically) attributable to cancer, as recorded in the patient's clinical
history, and medical diagnosis in five cancer sites (lung; breast, stomach, colon,
444 MEDICAL ANTHROPOLOGY QUARTERLY

and rectum) was assessed for its relationship to tumor stage at diagnosis and impact
on the length of survival time. Except in breast cancer, the association was statisti-
cally weak, leading my colleagues to challenge accepted clinical wisdom about
early detection as the key to a good prognosis. The duration of symptoms, they
concluded, was a "highly complex variable reflecting patient and physician behav-
iour, the clinical course, the functioning of the health system, sociocultural values,
and tumor biology" (Porta et al. 1991:228).
The "sociocultural values" in question are described as "psychosocial factors
. . . the patient's personality, education, income, and access to care" (Porta et al.
1991:229). The personality factors most related to patient delay in consulting a
physician appear in the medical literature as ignorance, fear, denial, and fatalism
(Estape et al. 1992:453; Perez-Stable et al. 1992). This use of "culture" to identify
personal characteristics is further complicated by the broad semantic range of this
term in Catalan and in Castilian (Spanish), which extends from something anthro-
pologists could recognize as the central concept of their discipline to good man-
ners, class position, and learning of the sort acquired from books and universities.
The social inferiority of individuals and groups lacking these refinements—and
the powers of rational thought they are presumed to confer—would be phrased in
everyday speech as afalta de cultura (lack of culture) so that, paradoxically, those
who lack culture also possess it in a form that marks them as problematic Others.
In this view, culture loses its status as the context in which experience is
meaningful and action intelligible, and is approached instead as a set of measure-
ment problems.3 The result—presented in two doctoral theses (Belloc 1993;
Molina 1993) on diagnostic delay successfully defended in my department—is a
series of antiethnographic questions about patient "error" with respect to the iden-
tification of the "first" symptom, whether the patient is "really" telling the "truth,"
what the patient "really knows," and what the patient "really wants to know." Pa-
tient accounts of the onset of cancer symptoms were judged more reliable if they
were internally consistent, resembled the clinical history, and coincided with the
physician's identification of thefirstsymptom. Underlying these judgments about
the validity of patient self-reports is a deep mistrust of the patient's subjectivity,
coupled with an inability to recognize medical subjectivity at work.4 This is re-
vealed perhaps most clearly in the tendency to extend greater credence to the ac-
counts of those patients who most resembled the physician-interviewer: married,
with more years of formal education (i.e., one of the components of culture in its
"rational thought" sense) and higher socioeconomic status.
From this point of view, then, the epidemiologist's problem is discovering the
social and cultural "risk factors" that predispose a patient to "diagnostic delay,"
which is conceived as a kind of disease (in a manner analogous to the clinical appli-
cations of the concept ofrisk[Gifford 1986]) that can only be prevented effectively
through presymptomatic detection of cancer (Porta et al. 1991:229). This under-
standing of the problem is based on five underlying assumptions, all of them seri-
ously at odds with ethnographic practice:
1. It is possible to isolate cultural concepts from their context without
important loss of meaning.
The study of "beliefs" and "attitudes," or more pejoratively, "misconcep-
tions" and even "myths" about cancer is undertaken with an eye to
CAN THERE BE A "CULTURAL EPIDEMIOLOGY"? 445

correcting or replacing them with "information" and "knowledge" through

education appropriately geared to comprehension level (see, for example,
Loehrer et al. 1991). It is simply a matter of interchangeable parts: replacing
a defective part with one that works properly. This is based implicitly, as I
have noted above, on a naturalist epistemology that takes language to be a
purely referential code.
2. It is possible to reify culture as "values," "attitudes," or "beliefs" that attach
to a particular social group, identified in ethnic, class, or behavioral terms,
which is also reified and essentialized, represented as internally homoge-
neous, and marked as problematic (cf. Good 1994:39; Yoder
1997:138-139).
This case is explicitly argued in a JAMA article comparing "Anglo" to
"Latino" perceptions about cancer in the United States (Pe'rez-Stable et al.
1992). The sample was drawn from the membership of a prepaid health
care plan in San Francisco and Alameda counties in California. Subjects
had to have been plan members for at least five years, which suggests stable,
nonmarginal forms of employment. Latinos in the sample (identified by
surname) were mostly immigrants, but also mostly U.S. residents of long
standing. However, the authors argue that even after adjusting for such
confounding variables as education, age, sex, county of residence, self-per-
ceived health status, and employment, Latinos as an ethnic group remain
more likely than Anglos to harbor "misconceptions" about the causes and
symptoms of cancer, and "attitudes"—"fatalism" being the one of primary
importance in the authors' view—that hinder efforts at cancer control and
cause avoidable delays in diagnosis and treatment (Perez-Stable et al.
1992:3222).
3. Culture may be understood either as a "protective factor" or as a "risk
factor," but mainly it is a risk factor.
The above-mentioned JAMA article argues that the Latino high-fiber diet
and lower smoking rates for women have given this group lower cancer
death rates than the U.S. population as a whole. However, what begins as
a "protective" factor quickly turns into a **risk factor." According to the article,
Latinos are also undereducated and culturally disposed to be "fatalistic." '"Latino
fatalism" then becomes a kind of disease requiring culturally specific treatment
to maintain a lower cancer death rate (Perez-Stable et al. 1992:3223). More
positive cultural values such as "the heightened concerns with family (fa-
milismo), the importance of positive interpersonal interactions (simpatia)
[and] the respect for authority figures (respeto)" are mentioned early in the
article (1992:3219), but never referred to again, their only value being,
apparently, to establish the "Otherness" of Latino culture. Instead of conclud-
ing that Latinos might be doing something right, the authors conclude that,
because Latinos have culture, they must be doing something wrong.
4. Only Others (defined, again, in ethnic, class, or behavioral terms) have
culture. Science is located beyond the boundaries of culture and consists
of universal knowledge free of local "bias."
A study of Spanish professionals with university degrees discovered that
although the respondents were generally well informed about carcinogens
and the value of prevention and early detection, even the physicians among
446 MEDICAL ANTHROPOLOGY QUARTERLY

this well-educated sample—much to the researchers' surprise—ranked

environmental pollution right after smoking as a cause of cancer (Conill
et al. 1989:27). Presumably, the respondents, especially the physicians,
should have been aware that currently accepted epidemiological wisdom
(see, for example, Doll and Peto 1981) regards only a very small propor-
tion—between one and five percent—of all cancer deaths as attributable
to air and water pollution. Balshem's extended analysis of a case in which
the widow of a young man who died of pancreatic cancer disputes the
content of his medical history with her husband's physician suggests that
working-class people resent and resist the implication of blame in the
biomedical emphasis on the carcinogenic effects of tobacco and alcohol
consumption (1993:108-109). In the view of the widow and her, working-
class, white-ethnic neighbors, exposure to industrial carcinogens is at least
of equal importance. What surprises Conill and his coauthors, then, is the
inexplicable Otherness of physician responses to their questions.
5. When "attitudes," "values," or "beliefs" are identified as "cultural," and
attributed to ethnic groups or the lower social orders, they become back-
ward and unreasonable, evidence of misinformation at best, and of willful
ignorance at worst.

In her analysis of "Project CAN-DO," a five-year cancer education campaign

aimed at the residents of a working-class, white-ethnic neighborhood in Philadel-
phia, Martha Balshem examines a list of seven "misconceptions" about cancer that
led project staff to see the target population as "fatalistic" and "hard to reach"
(1993:64-66). Considered separately from the cultural and class context to which
they were attributed, none of these notions is particularly irrational, and indeed, as
Balshem points out (1993:8-9, 65-66), scientific evidence supports a number of
them (for example, cancer surgery is known to release showers of malignant cells
into the bloodstream, increasing the risk that the disease will spread).
From my epidemiological colleagues' point of view, then, it is a matter of dis-
covering the social or cultural "risk factors" that predispose a cancer patient to di-
agnostic delay, which is conceptualized much as if it were a disease. Culture easily
becomes a proxy for the working class, a "master image of inferiority" (Balshem
1993:145) that justifies the exercise of medical authority. Although delay arising
from the health care system was acknowledged as a significant factor, the "delay
attributable to the patient" continued to receive the greatest emphasis, because, be-
ing located in the individual, it was regarded as more easily modifiable by appeal to
"rational" self-interest. In an attempt to reduce the implication of blame, the term
diagnostic delay was later abandoned in favor of symptom-to-diagnosis interval,
but this alters nothing in the medicalizing, diagnostic gaze of the epidemiologist.
The research problem remained situated (cf. Porta 1984:291) within the semantic
field of "patient compliance," an ideology that gives rise to potentially coercive in-
terventions that appear appropriate because they are intended to improve the effec-
tiveness of medical treatment (Trostle 1988). The factorization of the concept of
culture in this context does violence not only to anthropological theory, but to can-
cer patients, contributing to the production of a "metaphoric double" composed of
the "cultural images, metaphors, and collective representations that gather around
particularly dreaded and mortal wounds and diseases" (Scheper-Hughes and Lock
CAN THERE BE A "CULTURAL EPIDEMIOLOGY"? 447

1986:137), an excess of meaning that weighs heavily on those already carrying the
burden of their disease (see Susan Sontag's 1978 essay "Illness as Metaphor," and
DiGiacomo 1992 for an analysis of confluent notions of patient responsibility in
biomedical, anthropological, and popular discourses on cancer).

The Anthropologist's View

Throughout my two years in the epidemiology department, I attempted to
shift the discussion from "cultural factors" and their measurement to the cultural
context of illness experience for the cancer patient. Generally, in Mediterranean
European countries, biomedical and popular discourses on cancer coincide on a
key point: the dangers of disclosing the diagnosis to the patient (Thomsen et al.
1993; see Gordon 1990 for an analysis of the Italian case). This is the central cul-
tural drama of cancer, and it colors all phases of the illness. The general tendency is
to inform the patient's closest family members (usually spouses and/or adult chil-
dren) and leave the decision to tell the patient (or not) in their hands. Family mem-
bers typically act as a filter, or even a barrier, between physician and patient, often
initiating—or forcing—a conspiracy of silence that marginalizes patients even as
they endure the rigors of chemotherapy and radiotherapy (Dura Ferrandis 1990:43;
Morlans 1994:115).
This way of proceeding is justified by a logic riddled with internal inconsis-
tencies and contradictions, which I summarize here as a series of propositions (see
Estape*etal. 1992):
1. Cancer patients do not want to know their diagnosis.
2. Cancer patients only know their diagnosis if they are explicitly told.
3. Cancer patients already know, guess, or sense that they have cancer, and
therefore, it is unnecessary to tell them.
4. If cancer patients are told their diagnosis, they become distressed (s'an-
goixen) and often depressed, and may even attempt suicide.
5. Close family members know better than the patient him or herself, and
better than the doctor as well, whether the patient should be told the
diagnosis or not.
6. It is certain that cancer patients accept "alternative diagnoses" offered by
their physician (such as "inflammation," "infection," "cyst," "lump," "in-
testinal blockage," etc.), because they request no further information from
their doctors.
7. Cancer patients accept the need for chemotherapy (generally referred to as
"serum") and/or radiotherapy; but at the same time they want their doctors
to assure them that they do not have cancer.
8. Denial is psychologically essential if patients are to adapt well to their
illness.
9. Only scientific information about cancer, made available to the public
through modern and effective health education and health promotion
campaigns, will do away with the need for silence and denial.
Notice the inconsistencies. Cancer patients are believed to accept at its face
value a false ("alternative") diagnosis, but at the same time, they want their doctors
to reassure them that what they have is not cancer. Nevertheless, physician and
448 MEDICAL ANTHROPOLOGY QUARTERLY

family believe the patient already knows or guesses the diagnosis, and for this rea-
son does not resist known anticancer treatments. However, explicit mention of the
diagnosis is thought likely to provoke severe depression, sometimes culminating in
suicide.
I cannot believe that cancer patients truly "do not know" what they have un-
less explicitly told. It seems likelier to me that the lexicon of euphemisms and cir-
cumlocutions used by physicians and family members, and even the quality of the
silences in conversation surrounding a diagnosis of cancer, constitute a social code
so firmly established and so well understood that it would be very difficult, not to
say impossible, for adult cancer patients to remain ignorant of it. If cancer patients
accept "alternative" (false) diagnoses, but are nonetheless assumed to "sense" or
"guess" the real diagnosis, then nondisclosure of the diagnosis is about something
other than information. It is not knowledge that is at issue, but acknowledgment, in
public social space, of a diagnosis of cancer. Such acknowledgment is widely be-
lieved, even by physicians, to be tantamount to a death sentence (see Estape et al.
1992; Senra Varela et al. 1988). The culturally constructed ambiguity in speaking
about cancer is, then, a social fact whose importance lies not in private emotions,
but in public ones. The "harm" widely supposed to come from learning a diagnosis
of cancer is not a private harm, but a public one, just as silence and euphemism
have public consequences. The effect of silence or an "alternative diagnosis" is not
so much to comfort or console the patient as it is to tranquilize or sedate him (see
Gordon 1990), and this may actually provoke the social death it is intended to pre-
vent.
This dominant cultural model is, however, beginning to weaken under the
pressure of its own internal contradictions in a cultural context that is no longer the
same as it was a generation earlier (Rihuete et al. 1993). Many younger physi-
cians—those who have come of age since the mid-1960s, during the final years of
the Franco dictatorship and the subsequent transition to and consolidation of de-
mocracy—share their contemporaries' well-founded mistrust of established
authority and received wisdom (Morlans 1994:70). They are no longer comfort-
able with benevolent paternalism (see Conill and Lozano 1988), but they have very
little in the way of alternative models to guide them. At some level, they are aware
that abandoning the old model will involve reinventing professional authority on a
very different ground, a particularly daunting task for professionals whose training
has never prepared them for this kind or degree of reflexivity but whose daily clini-
cal experience is forcing it upon them (see Roig 1991). Some patients have met
physicians more than halfway in this search for a new model. Particularly compel-
ling is a recent book by Albert Fina, who died early in 1997 of colon cancer.

It has always surprised me that many patients remain ignorant of the nature of
their illness. In some cases, too often, they do not even know its name. Informa-
tion is neither offered nor desired.... We have no choice but to live with our ill-
ness, in my case cancer, even though it turns out to be a poor friend indeed. We
ought to know our enemies, especially when they can cause our death.
[1996:86-87, author's translation]

He might easily have said the same of his political enemy, the Franco regime,
which he fought for more than 15 years in the courts as a labor lawyer.
CAN THERE BE A "CULTURAL EPIDEMIOLOGY"? 449

It is this reinvention of the physician-patient relationship and of professional

authority in the context of cancer treatment that I wanted to make the subject of my
research. I saw this as a first step toward being able to achieve something more than
the reduction of culture to a set of measurable factors amenable to statistical analy-
sis yielding a result that looks valid only because it has been quantified. I was call-
ing attention, in short, to the depoliticizing effects of a medicalized conception of
diagnostic delay (see Frankenberg 1993:234).
In everyday practice, the physicians with whom I became acquainted in the
public hospital attached to the research institute dreaded making a diagnosis of
cancer, and tended to handle the problem by passing the patient along to the oncol-
ogy service as quickly as possible and with minimal explanation; no one wanted to
be responsible for pronouncing a "death sentence" (Cimas Hernando et al.
1996:188-189). Oncologists felt similarly constrained, but for different reasons.
Most of their patients reached them at a very advanced point in the course of their
disease, when aggressive treatment was unlikely to result in long-term remission
but was certain to produce a great deal of short-term pain and misery. Additionally,
the oncology service was also the end-point of what was often an exceedingly long
trajectory through the health care system. Most cancer patients were likely to have
seen many different physicians, but the oncologist had to rely on family members'
accounts of how much or what kind of information any of those physicians had im-
parted to the patient. The need to keep careful track of the complex web of evasions
and half-truths further burdened the already-overworked oncology staff, but the al-
ternative—giving the diagnosis its true name—seemed like a gratuitously cruel
gesture toward suffering patients nearing the end of their lives. Nevertheless, one
oncologist explained to me that he experienced the silence around the diagnosis as
an insurmountable barrier to any kind of meaningful communication with the pa-
tient. Accompanying him on his hospital rounds, I could see in his posture and hear
in his voice the accumulating tension of repeated encounters with this barrier.

Conclusions
The political and personal reasons I was not allowed to focus my research on
this state of affairs—in fact, why I was systematically frustrated—are the subject
of a future article, the fourth in the series. For my purposes here, I want to stress the
epistemological reasons why my proposal met such resistance. At the November
1995 American Anthropological Association meetings, during a luncheon round-
table discussion on the theme of "Anthropology and Epidemiology: What's Cul-
ture Got to Do With It?," William Dressier, the organizer, recounted a joke about
one of Mozart's patrons, whose reaction upon hearing the composition he had
commissioned was "Very nice; but so many notes!" Dressier, whose work on hy-
pertension among African Americans represents some of the very best fruit yielded
by the contact between epidemiology and anthropology, observed that he had often
gotten an analogous reaction from epidemiologists to ethnography: very nice, but
so many words! The place of contextualization—what Clifford Geertz, borrowing
a useful notion from Gilbert Ryle, calls "thick description" (1973:6)—in ethno-
graphic explanation is not well understood by epidemiologists, because context in
epidemiology is established so differently: by highly detailed descriptions of
method. Indeed, Krieger argues that contemporary epidemiology is practiced,
450 MEDICAL ANTHROPOLOGY QUARTERLY

understood, and taught as method not only in the simple absence of theory, but also
in the absence of any awareness that theory is lacking (1994:899). And
epidemiologic methodology, in turn, rests on the naturalist epistemology I de-
scribed at the beginning of this article.
True argues that "anthropologists need to judge [epidemiological] work by
the questions asked, not by the methods used" in order to locate or create a com-
mon ground which would permit the two disciplines to work fruitfully together
(1990:317-318). Hahn would go even further, arguing that apparent differences in
the explicitly articulated logics and methods of anthropology and epidemiology
are merely superficial and "their underlying epistemologies are fundamentally
complementary. There is no contradiction and much common ground" (1995:111).
I would counter these arguments by pointing out that our methods shape both
the kinds of research questions we can conceive and the strategies of explanation
we pursue. By way of illustration, it is worth digressing briefly to consider the pre-
dicament of a historical sociologist whose dissertation work focused on an
econometric analysis of strikes in Italy during the postwar period.
Trained in arigorouslyquantitative doctoral program, Roberto Franzosi was
proud of the new, provocative, and statistically significant results he was getting,
until an Italian colleague, during a public presentation of the dissertation work at
an Italian research institute, pointed out that all statistical work reflects correla-
tional relationships, not causal ones (Franzosi 1996:356). When he got over his in-
itial outrage sufficiently to be able to admit to himself that in fact he had already
begun to have doubts, Franzosi realized that what his statistical work had alerted
him to was "the vulnerability of our empirical findings to issues of data defini-
tions" (1996:357). As he pursued the question of causality though his data, he was
startled to discover that the dazzling sophistication of his statistical models had
blinded him to a seriously distorting characteristic of yearly statistics: that they are
constructed with a December 31 cut-off point. In his own research, a strike in the
fall of one year, followed by a wage increase that took effect on January 1 of the
following year, shows up statistically as a negative relationship of strikes and
wages, although the true relationship, in the unfolding of historical events, was
positive (1996:358).
In the practices of sociologists engaged in the quantitative study of historical
processes, Franzosi argues (1996:384; he prefers to let historians and other soci-
ologists worry about their own practices), the subordination of all other considera-
tions to valid and reliable quantification through hypothesis testing constitutes a
ritual that, paradoxically, obscures "the invaluable role that good statistical work
can play in bringing out patterns in the data" (1996:365). At the same time, history
is treated as a "warehouse of data" to be plundered for useful bits of information.
And so, despite appearances, Franzosi concludes, citing Braudel, that "there is
hardly ever any real dialogue between sociologist and historian," and certainly no
marriage between two disciplines that would seem to be ideally suited mates
(1996:384). Likewise, I conclude that there has been little real dialogue, much less
a marriage, between anthropology and epidemiology.
What I am suggesting here is that in epidemiological work, anthropology oc-
cupies the "warehouse of data" role reserved for history in relation to quantitative
sociology: local knowledge, cast as "beliefs," serves as the ground from which anthro-
pologists can negotiate their relevance in public health and epidemiological research
CAN THERE BE A "CULTURAL EPIDEMIOLOGY"? 451

projects (Yoder 1997). Anthropology is raided for bits of information about "cul-
ture" which can then be plugged into a statistical model that generates correlations
amenable to being represented as causal, and to being rhetorically packaged in the
"elegant display of statistical virtuosity" (Franzosi 1996:362) favored by the main
journals in the field.
It is worth pointing out in this connection that everyone in the epidemiology
department where I worked was acutely aware of the pressures emanating from the
office of the institute's director to publish frequently in journals with a high "bibli-
ographic impact factor," that is, the heavily cited "source publications" listed in
Journal Citation Reports, the Science Citation Index, and so forth. In fact, the head
of my research area devoted an entire departmental seminar to an extended expli-
cation of this concept (Porta n.d.). As his presentation noted, the status hierarchy
evident in the designation of some journals as having source status leads inevitably
to reflections about not just how we cite, but what we cite in what we write, what
we say and don't say, where we try to publish our work, and how far we can stray
outside the implicit rules of what constitutes what we might think of as "source-
quality epidemiology." Ironically, his ability to see the constraining effects on the
epidemiological imagination of too-close adherence to these implicit rules in no
sense prevented him from trying to force my ethnographic inquiry to remain within
them as a mere "warehouse of data."
The problem, then, is considerably more serious than Dunn and Janes (1986)
suggest when they identify the main obstacle to collaborative endeavors as the dif-
ference between quantitative research, with its emphasis on reliability, and qualita-
tive research, with its advantages in terms of validity. "Although one kind of meas-
urement is very difficult to combine with the other in a single step," they argue,
"qualitative and quantitative measurement may inform the other [sic] at different
stages of the research process" (1986:20; emphasis added).
In reply, I would point out, with Franzosi (1996:386), that research questions
are all too often determined by the availability or absence of quantitative data. I am
not (nor is Franzosi) ideologically opposed to quantitative work as such. He ar-
gues, and I fully agree with him, that qualitative approaches to history and social
life can become ritualized in their own way, focused on form at the expense of con-
tent, and that "ritualized historical or sociological work, whether quantitative or
qualitative, is very likely to be bad work" (Franzosi 1996:385). But just as there are
historical and social questions that can be addressed successfully through the use
of quantitative methods, there are others that "are simply 'undoable' at the present
state of quantification" (Franzosi 1996:386). My proposed contribution to the di-
agnostic delay study was one of the latter, and the project simply did not include
room for such a small-scale, qualitative ethnographic study. There is an important
lesson to be drawn from this: the project design must be a joint undertaking. The
necessary negotiations will take time, time is expensive, and expense requires ad-
justments in the way grant applications are written and the pace at which research
results are published. The requirements, then, of genuinely collaborative work go
well beyond matters of epistemology to include the politics of scientific research,
and demand some degree of courage from all concerned, but especially from epide-
miologists in pursuing lines of research that do not necessarily promise fast returns
with high bibliographic impact value.
452 MEDICAL ANTHROPOLOGY QUARTERLY

Positioned at this "present state of quantification," ethnographic and epi-

demiological accounts are not parallel, complementary narratives, but divergent
narratives. This does not mean that they cannot speak usefully to each other, but for
a very long time this conversation has required a disproportionate and unrecipro-
cated effort on the part of anthropologists to meet scientists on their own concep-
tual and methodological ground (Balshem 1993:128). If we are to get beyond the
reification and factorization of the concept of culture, epidemiologists must meet
anthropology halfway, by learning the reflexive practices that will lead them to
what Franzosi calls "a theory of the data, a theory that deals not only with the web
of relationships within the data but also with the process by which the data are gen-
erated" (1996:363).

NOTES

Acknowledgments. My thanks to the participants of William Dressier's roundtable dis-

cussion group "Anthropology and Epidemiology: What's Culture Got to Do With It?" at the
1995 meetings of the American Anthropological Association for the opportunity to try out in
a congenial setting some of the ideas in this article, Johannes Sommerfeld for inviting me to
formalize my part of the discussion in the form of a short article in the IHIDSG Newsletter,
Oriol Pi-Sunyer for a critical reading of successive drafts, the anonymous reviewers, and
both the former and the current editors of this journal.
The fieldwork on which this article is based was possible thanks to a half-year position
as Visiting Professor in the Faculty of Medicine, Universitat Autbnoma de Barcelona, from
February to July 1992, and a research grant (ref. SB92-AH0073116) from the Spanish Min-
istry of Education and Science for the calendar year 1993.1 would like to thank my physi-
cian colleagues at Barcelona's Hospital del Mar—Dr. Manel Gallon, Dr. Joan Sancho, Dr.
Catalina Vadell, Dr. Joaquim Gea, Dr. Joan Broquetas, Dr. Josep Planas, and the late Dr.
Xavier Aran—for sharing their stories of medical practice with me and allowing me to ob-
serve tumor board conferences and interactions with patients; Dr. Xavier Altarriba for long
conversations on medical ethics and doctor-patient communication in cancer treatment;
Joaquim Puyal for introducing me both to Dr. Altarriba and to the world of media repre-
sentations of cancer; Prof. Jesus de Miguel of the Department of Sociology, University of
Barcelona, for his ongoing friendship and for furnishing me with an opportunity to speak to
his graduate seminar in medical sociology; Prof. Josep Comelles of the Department of An-
thropology, Universitat Rovira i Virgili (Tarragona) and the students in his M.A. program in
medical anthropology, who were a lively and critical audience for the presentation of parts
of this paper; Montserrat Miralles for teaching me how to use a computer; Andrew Maguire
for demystifying medical statistics; colleagues from other research areas in my department,
especially Dr. Richard Hartnoll, Dr. Jordi Sunyer, Dr. Antonia Domingo, and Dr. Josep
Ant6, for their willingness to help me understand what epidemiologists do; and the former
graduate students of the Department of Epidemiology, Municipal Institute of Medical Re-
search, Barcelona, most especially Dr. Esteve Fernandez and Dr. Laura Gavalda, for their
continuing intellectual and human comradeship.
Correspondence may be addressed to the author at the Department of Anthropology,
Machmer Hall, University of Massachusetts at Amherst, Box 34805, Amherst, MA
01003^1805.
1. The diagnostic delay research group included an oncologist completing a master's
degree in public health. He was nearly as desperate to find something in the epidemiology of
diagnostic delay that was relevant to his everyday clinical practice in a public hospital serv-
ing some of the poorest districts in the sity as I was to find a way of participating in the pro-
ject which did not require me to discard my conceptual and theoretical apparatus. Early
CAN THERE BE A "CULTURAL EPIDEMIOLOGY"? 453

detection has long been regarded as the master key to successful cancer treatment, but the
head of our research group was inclined to believe instead, on the basis of a statistical analy-
sis of the relationship between duration of symptoms, tumor stage, and survival in five tu-
mor sites (Porta et al. 1991), that tumor biology may be the controlling factor in survival
rates. Simply put, patients with more virulent tumors will die quickly no matter how early
they are diagnosed and treated. Whatever the value of this work as a contribution to
epidemiological knowledge, the oncologist read it through the lens of the widespread public
perception of cancer as unbeatable and invariably fatal, a fear that may have a great deal to
do with why so many of the cancer patients in his care present, to his great distress and frus-
tration, with late-stage disseminated disease.
2. Acculturation studies tended to focus on experiences of deprivation, and to find the
evidence of resulting cultural disorganization in personality conflicts (see Voget 1973:
43-46), an approach that seems to facilitate the epidemiological construction of the poor as a
problematic social category requiring scientific management (see Dreyfus and Rabinow
1983; Foucault 1983).
3. I am indebted to an anonymous reviewer for the neatly framed insight that epidemi-
ologists wait vainly for anthropologists to provide them with measurement tools and, when
these tools are not forthcoming, then proceed to "factorize" culture.
4. This selective blindness is a consequence, I would argue, of the inarticulate belief
that what they are measuring possesses objective reality in the natural world. For example,
in a seminar unrelated to the diagnostic delay project (the subject was "interethnic variation
of drug metabolism"), the speaker used a set of muddled racial categories that separated
"Spaniards" from "Caucasians," the latter category defined as "the Anglo-Saxon population
of Europe," which inexplicably included the French but excluded the Australians, many of
whose ancestors were Anglo-Saxon convicts transported by the British government to what
began as a prison colony in the late 18th century (see Hughes 1987). When I questioned the
validity of these categories, the speaker reacted first with surprise, then with irritation, at
what she perceived as my ignorance: these were the standard categories in the pharmacology
and genetics literature. The head of my research area, also present in the audience, dismissed
my questions as unimportant, explaining patronizingly that classifying populations by race
was of precisely the same order as classifying them by sex. It would be hard to find a better
demonstration of the effect of epistemology on both method and measurement.

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Acceptedfor publication May 4,1989