Fabrega H. 1971. Medical Anthropology. Biennial Review of Anthropology 1

Stanford University Press
Medical Anthropology
Author(s): Horacio Fabrega, Jr.
Source: Biennial Review of Anthropology, Vol. 7 (1971), pp. 167-229
Published by: Stanford University Press
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3
MEDICAL ANTHROPOLOGY
HoracioFabrega,
Jr. * MichiganStateUniversity
INTRODUCJON
In thisreviewI willadoptthedefinition ofmedicalanthropology that
is usedimplicitly
byworkers in thefield.In thisdefinition,neithercon-
cepts,methods, noraimsarecriterial, butrather thecontent ofthework
thatis performed. A medicalanthropological inquirywillbe definedas
onethat(a) elucidatesthefactors, mechanisms, andprocessesthatplay
a roleinorinfluencethewayinwhichindividuals andgroupsareaffected
byandrespondtoillnessand disease,and (b) examines theseproblems
withan emphasison patternsof behavior.Primaryemphasiswill be
givento studiesthatare conductedin non-Western settingsand that
relyon the conceptof culture.
Two broadtypesofemphasescanbe discerned in thefielddescribed
aboveas medicalanthropology, theetimomedical and theWesternbio-
medical.In thefirsttype,medicalproblemsare approachedfromthe
viewpointof thegroupsand individuals studied.That is, illnesstends
to be viewedas a culturalcategoryand as a set of culturally related
events.(When an investigator adoptsan emic standpoint towarda
medicalproblem, theword"illness"'willbe used to label theanalytic
unit.) Studiesof thistypeare heretermedethnomedical and are re-
viewedinthischapter. It willbe observedthatin ethnomedical studies,
behavioraland phenomenologic indicators are usuallyemployedto de-
PeterK. Manningand Elena Padilla read earlierversionsofthischapterand offered

criticalcommentsthatwerehelpfulto me. I wishto also acknowledgethe assistance
of Mrs. MartineZuckerand Miss Carole Ann Wallace. Miss SherrilynBoatman
patientlytypedthe severalversionsof thischapter,and I wishto acknowledgeher
help.
* This and othertechnicaltermsused in thischapterwill be explainedon pp.
213-14.

168 HORACIO FABREGA, JR.
finea stateofillness.Attheotherextreme arestudiesthatviewmedical

problemsusingthe categories of Westernscientific medicine.The or-
ganizingperspective towarddiseasein thesestudiesis a biologistic one.
Thatis,emphasisis givento diseaseas an abnormality in thestructure
and/orfunction ofanysystem ofthebody,and evidencesofbiological
systemmalfunction serveas indicators of disease.(When theinvesti-
gatoradoptsthisparticular eticframework, theword"disease"willbe
usedtolabeltheanalytic unit.)In manystudiesthatuseWestern medi-
cal diseasecategories,thebeliefs,perceptions, orpracticesofthegroup
regarding diseaseare notemphasized. The presumedcausesor conse-
quencesof disease,however,maybe examinedwithan emphasison
social and culturalfactors.Such studies,whichmightbe termedepi-
demiological or ecological,willbe reviewed.As willbe seen,questions
of a geneticand ofan evolutionary natureand/orconcernsof popula-
tionbiologyoftenpredominate in theselatterstudies.
At thetimethischapterwas prepared,thereexistedno generalre-
viewofthefieldofmedicalanthropology sinceNormanScotch'schap-
terin the 1963 editionof the BiennialReview.Consequently, I have
takenthe endpointof his reviewas a starting pointformyown and
havemadean attempt to examinetheliterature sincethattime(Janu-
ary1963). Myreview,whichis selective, coverstheliterature through
1970,althoughoccasionalpapersthatappearedearlyin 1971 are in-
cluded.I have triedto includeas manyitemsas possiblein orderto
providea sourcethatothersmightuse as a beginning fortheirown
researchefforts.
Asidefromexceptional casesthatprovetheoretically productive, I did
notattempt inthischaptertoreviewliterature dealingwiththemedical
"needs"orproblems ofunderdeveloped countries.The readerwishinga
cleardelineation oftheseissuesis urgedto consultthebookby Bryant
(1969), whichrepresents an in-depth studyofthistype.In addition, no
attemptwas madeto reviewarticlesdealingwiththeeffects ofhealth
careprograms and theproblems(eithershort- orlong-range) thatthey
can create.The articleby Hughesand Hunter(1970), whichemploys
a broad ecologicframework, providesa lucid and rathercomprehen-
siveaccountoftheunanticipated and negativeconsequences ofhealth-
relatedprograms in Africa,and can be regardedas an exampleof the
criticalposturethatneedstobe adoptedwhenevaluating programmatic
effortsofthistype.The twobooksbyVanAmelsvoort (1964) andAdair
and Deuschle(1970) are in-depth analysesoftheexperiences encoun-
teredduringtheimplementation of medicalcare programs in settings

MEDICAL ANTHROPOLOGY 169
governedby non-Westernmedical systemsand should be consulted.
Studies emphasizingphysiologicaladaptation to harsh environmental
settings(e.g. acclimatizationto high altitude,to cold weather,etc.),
physical and genetic characteristicsof individuals (e.g. blood group
types,body composition,etc.), and the diet and nutritionof groups
will not be reviewedunless disease problemsare directlyfocusedupon
in the contextof social and culturalfactors.Similarly,studiesthatadopt
an exclusivelybiologisticframeworkwhen examiningdisease (e.g. a
studyreportingthe frequencyof arbovirusY antibodiesin the sera of
individualsof X culture) are givenlesseremphasisin thischapter.And
last, literaturedealing with issues bearing on the disciplineof anthro-
pology,and particularlyits relationshipto medicine,was not reviewed.
Those interestedin tracingthe many pointsof contactbetween medi-
cine and anthropology are urgedto read thebook editedby Von Mering
and Kasdan (1970). The chaptersin thatbook representsummarystate-
mentsof how anthropologyrelates to otheracademic disciplines,and
particularemphasisis given to the linkage between anthropologyand
the health sciences.
GENERAL WORKS
In Cebuano Sorcery(1967), Lieban analyzes the social and cultural

factorsthatorganizeand structuremedicallyrelevantbehaviorsin rural
and urban segmentsof the Philippines.Beliefs about the causes of ill-
ness,and themannerin whichthesebeliefsmotivatetheuse of sorcerers
and othermedicalpractitioners, are presented.Attentionis also givento
differenttypesof problematicsocial behaviorsthat are independentof
(althoughoftencoexistentwith) illnessand disease, and thatalso occa-
sion the use of sorcery.Throughoutthe book, the reader is kept in-
formedof the way in whichindividualsoscillatebetween and relate to
the two prevailingand quite different medical traditions,namely the
ethnomedicaland the Western biomedical. The illustrativecases are
rich in detail.
The Blums depict illness and medical care experienceswith refer-
ence to social processes and traditionsin rural communitiesof Greece
(1965). They also analyze information collected by means of a survey
thatinquiredabout medical beliefsand attitudes,actual occurrencesof
specificillnesses,and use of medical facilitiesand practitionersin the
area. Even the responsesof the villagersto a medical evaluation and
theirdegree of compliance with physicianadvice are described. The

170 HORACIO FABREGA,JR.
study,in short,attemptsto reviewall facetsof illness,disease,and

medicalcareinruralcommunities ofGreeceand adoptsboththeWest-
ernbiomedicaland the folkor emicframework. The veryambitious
scopeofthisstudytendsto militateagainstitsoverallvalue.Thus,the
intention oflinking social-epidemiologic findingswithdata aboutmedi-
cal care in a mannerthatcloselyadheresto culturally relevantcate-
goriesis largelyunrealized, theresultbeinga comprehensive but un-
evenaccountofmedicalmatters in thissetting.
Harwood(1970) studieddiseaseand deathamonga community of
Safwapeople in East Africa.His primary intentwas to explainthe
socialphenomena ofwitchcraft and sorcery as distributed in thecom-
munityby focusingon instancesof illnessand death.In doingso he
also discoveredsomeof the underlying medicalbeliefsand practices
thatprovidethecontext ofthesesocialactivities. The Safwa,he informs
us,tendto explainillnesslargelyin termsofdeviancesfromsocio-moral
normsthatlead to an ebbingofthelifeforce.Harwoodadoptsa rather
traditionalethnomedical framework andindicatesthat,quiteapartfrom
any physicalcharacteristics thatan illnessmay have,diagnosticand
actionalternatives are framedwithinthe socialrelationsand interac-
tionsof the person.
In a straightforward and unassuming manner, Read (1966) manages
tosuccinctly review the influence of sociocultural(e.g. healthtraditions,
socialpatterns,healthknowledge, folk modes ofcare, etc.) andenviron-
mentalfactors on the types of health problems that prevail amongpre-
literategroups,and also the way in which the groups handle these
problems.The issues stemming from competing health traditions, and
the resulting obstacles that militate against the acceptance of health
programs, are also reviewed.In thiscontext, attention is givento the
knowledgebase and skillsthatare desirableattributes of healthpro-
gram personnel.
The historian Vogel (1970) reviewsin a verythorough mannerin-
formation about medical beliefs,theories, practices, and therapeutics
amongNorthand SouthAmerican Indians,usingbothprimary and sec-
ondarysources.He presentshis materia-inthe contextof important
historicalevents,and discussessomeinstancesofrelationship between
Indianand colonialmedicalorientations and practices.The appendix
includesdetailedinformation on a largenumberofbotanicalitemsthat
havebeenorstillareofficial in thepharmacopoeia oftheUnitedStates
or theNationalFormulary. The bookis usefulas a reviewofmedical
dataaboutAmerican Indians.However,becauseofitsspecializedfocus,

MEDICAL ANTEROPOLOGY 171
anthropologists may not findit useful eithertheoreticallyor for their
own intendedfieldwork.
Kiev (1968) provides an analysis of curanderismoamong Mexican-
Americans,which he considersa "folkpsychiatry." The purpose of the
studywas to extend knowledge of the culturalaspects of psychiatric
theoryand treatment, and to depicthow culturalfactorsaffectthe form
and contentof Mexican-American folkmedical theoriesand treatment.
Kiev also intendedto studybroader issues such as personalityforma-
tion and psychic conflict,and particularlytheirrelationswith psychi-
atric illness in this setting.However, the justificationfor depicting
curanderismoas a "folkpsychiatry"involves a varietyof issues that
he does not make explicitin thisbook. The authorinterprets "folkpsy-
chiatry"in a verybroad and special sense, one that includes illnesses
that presentstrikingphysical symptoms(i.e. diarrhea,vomiting) and
the effectsof child-rearingmethods on adult personality,psychody-
namics, and therapeutictransactions.The book containsmuch useful
information cast in a predominantly psychoanalyticframework.It suf-
fers,however,frominadequate attentionto native concepts of abnor-
malityand excessivereliance upon insufficiently documentedanalyses.
For furtherexcellentinformation on Mexican-American medical beliefs
and practices,the readeris referredto Rubel (1966) and Clark (1970).
The book edited by Brim et al. (1970) containsessays dealing with
different facetsof death and dying,and focusesmainlyon the contem-
poraryAmericanscene. Medical, ethical, and social aspects of death
and the processesthatsurroundit are reviewed.The chaptersby Riley
and Knutson,whichfocus on orientationstowarddeath,includingcog-
nitiveand attitudinaldimensions,are likelyto be of interestto anthro-
pologists.Althoughthe book lacks cross-cultural data, it does represent
a usefulgeneralstatementon the problemof death and includesa good
bibliography.The collectionof papers edited by Weaver (1968) on
medical anthropologyrange ratherwidely in theirfocus and include
strictlypsychologicalconcerns,medical health aspects of the work of
public health nurses,folk medical care, functionalaspects of beliefs
concerningbirth,and aspects of the linkagebetween anthropologyand
epidemiology.
Three recentbooks by Buck et al. (1968b, 1970a, 1970b) havingpre-
dominantlyan epidemiologicalfocus are notable fortheircomprehen-
siveness and carefulpresentationof findings.These books are model
examples of what currentmedical technologyallows in the field of
internationalhealth.It is not possible to presenthere a succinctstate-

mentof the manymedical findingsreportedby these authors.In addi-

tion to the presentationof data dealing with amountsof various sys-
temicand localized parasiticand infectiousdiseases,the authorsreport
on such issues as communityorganization,demographicpatterns,envi-
ronmental-health parameters,hygienepractices,nutritionalhabits,and
othersocial activitiesthathave medical import.The manytypesof in-
formationcollectedare related mainlyto rathertraditionalconcernsof
public health and epidemiology;the amountsand distributions of dis-
ease, the characteristics
of the setting,and the livinghabitsand behav-
iors that are of relevance to morbidityare given principal attention.
Little attemptis made by these authorsto analyticallylink culturally
organized beliefs and patternsto the causes of the diseases that are
found,to disease manifestations and interpretations,or to the care of
those ill. The books,in short,are outstandingcontributions in the field
oofinternationaland communityhealth as well as epidemiology.
The book edited by Levine and Scotch (1970) includes a great deal
of information dealing with social and culturalaspects of stress,a con-
structthat is rathercentralto medicine and also of interestto social
scientistsconcernedwith deviantbehaviors.It will provide the reader
witha clear and broad expositionof the domain and relevanceof stress
as it relates to medicine and social science. Each chapterreviews in
depth a facet of stressthat has relevance for the study of disease in
social settings.The introductory chapterby Levine and Scotchis a suc-
cinct,lucid, and cogentlogical analysisof the way physiciansand social
scientistsuse theterm"stress."The penultimatechapterby Howard and
Scott expands on theirearlieroutstandingpaper dealing with a unified
frameworkfor analyzingstress (1965). The chapterby Cassel is also
of similarlyhigh quality and is a very useful analysis of the relation-
ship between stressand physicalhealth.
Several textbookson sociologicalaspects of medicinehave appeared
duringthe timeintervalconsideredin this review.Those by Freidson
(1970), Coe (1970), and Mechanic (1968) are likely to prove most
useful to anthropologists interestedin medical problems.Anthropolo-
gistsare especiallyreferredto part III of Freidson'stext;to Coe's treat-
ment of the perspectiveof the actor in the chain of illness behaviors;
and to the analysisby Mechanic of the many similaritiesbetween the
studyof disease and deviance and of the role of the perspectiveof the
doctorand patient,respectively, on the natureof illnessand health.The
bibliographyin the last is excellent,containingnearly500 items.
Few books can begin to approach the range and depth that Dubos's

Man Adapting(1965) manages to conveyabout the manyinterrelated
factorsthat affectman's biological adaptation and that underlie and
coexistwith his recognized health problems.Dubos summarizesand
criticallyexamines biomedical informationfrommany diverse fields
such as microbiology, human development,genetics,nutrition,clinical
medicine,and bioclimatology.It is importantto emphasize that this
book is not just "another"generaland discursivereviewof "basic" eco-
logic issues that are relevantto health. Rather,it provides a refined
analysisof the manycomplexfactorsinvolvingman's biological nature
and the physical aspects of his environmentthat have a bearing on
his health and adjustment.Disease to Dubos is not a discontinuous
qualitativestatethatman simplyentersintoor passes through.Instead,
disease is viewed as temporarysetbacks in the perpetual strugglebe-
tween man and the forcesof nature. Man and the human group are
viewed as standingin an "open" relationshipwithnature,such thatthe
biological and social levels of human activityare, in a literal sense,
structurally and functionallyinterpenetratedwith nature (i.e. with vi-
ruses, bacteria, waste products,climatologicalfactors,and periodici-
ties,etc.). Man is thusviewed as always "diseased"; the relevantques-
tionbecomes in what particularway and to what extentat thismoment
in time.This book is certainly"requiredreading"forall thoseinterested
in a systemsapproachto theproblemsofhumandisease and adaptation.
ETHNOMEDICAL STUDIES
This sectionis divided into six distinctsegments:medical beliefs,ill-

ness descriptions,contextof medical problemsand medical care, medi-
cal treatment, personalcharacteristicsof the medical practitioner,
and
summaryand critique. Given the broad characterof ethnomedicalstud-
ies, most literatureitemscould have been discussed withinalternative
segmentsof thissection,and in factdiscussionof some literatureitems
oftentranscendsthe specificcontentdomain of a segment.
MedicalBeliefs
A numberof investigators have givenprincipalattentionto the gen-
of illness.Laughlin's (1963) report,which
eral beliefs and definitions
focuseson generalmedical problems,emphasizesthe linkbetween be-
ofthe environment,
liefsand the characteristics givingattentionto some
of the factorsthatappear relevantin the acquisitionof medical knowl-
edge. The paper by Khare (1963) focuses mainlyon medical beliefs

held by residentsof Indian villages and stressesthe fact thatthese be-

liefsquite oftenlinkwith contrastingmedical systems.This reportex-
plicitlyconcernedthe influenceof these beliefson the implementation
of modernmedical programs.Schwartz's(1969) studyprovidesan ex-
cellentaccount of the socioculturalimplicationsof competingmedical
systems,a factorthat she analyzes fromthe standpointof hierarchies
of resortbut whichalso involvesreferencesto nativebeliefsand values.
This paper containsa numberofveryworthwhilesuggestionsregarding
how illnessand theway in whichit is definedand dealt withby a group
can be viewed analyticallywithreferenceto social and culturalchange.
In addition,the implicationsof the observationthatillnessis construed
as a moral categoryare carefullyexamined.In a more explicitlyethno-
scientificmanner,Fabrega, Metzger,and Williams (1970) pursue a re-
lated themewithrespectto the Maya Indians of Tenejapa. They dem-
onstratethat Tenejapa beliefsabout the causes of all types of illness,
not just illnessesindicatedby exclusivelysocial criteria,explicitlyrefer
to notionsof friendship,rivalry,envy,moral worth,and malevolence.
The applicationof these beliefsappeared to monitorthe importantso-
cial eventsand processesof the community. The studyby Fabrega and
Metzger (1968) focuses on related concernsamong Spanish-speaking
"ladino" residentsof Chiapas. This reportcontainsmore data on social
factorsand processeslinkedto what can be termed"psychiatric" issues.
The authorspointout the social and symboliccharacteristics of illnesses
indicated by exclusivelyinteractionaland sociopsychologicalcriteria.
The functionalconsequencesof the implementation of thesebeliefsare
also discussed.Opler's (1963) accountof illnessin ruralregionsof east-
ernUttarPradesh,India, also followsthe themeof the social and moral
basis of illness and reiteratesthe point that medical beliefs are con-
stituentsof thegeneralphilosophyof the culture.The papers by Currier
(1966) and Ingham (1970) are generalaccountsof the significanceof
the beliefsabout the conditionof the blood in illness.They see in them
a varietyof symbolictrendsthatplay a role in the process of socializa-
tion and in interpersonalrelationships.An interesting recentpaper by
Panoff(1970) focusesmore directlyon beliefsabout the body and the
blood, and linksthese beliefsto use of plants forremedies.A number
of authorshave given accounts of the use of botanical specimensfor
medical problems (e.g. Stopp 1963, Grover 1965, Jain 1965, Morton
1968a and 1968b), but theytend to deemphasize culturalpatternsand
values, particularlyas these relate to medical beliefs.
Lieban (1966) studied the relationshipbetween fatalisticbeliefsin

ChristianPhilippinesociety and the oftenpositive medical responses
of Filipinos in situationswhere such beliefs are relevant.Edgerton's
(1966) account of beliefs about psychosisin Africais extensiveand
includes data about notionsof etiology,descriptivefeaturesof behav-
iors felt to indicate psychosis,treatment,and prognosis.Of particular
value is the variabilitythathe uncoversregardingbehaviorsfeltto sig-
nifypsychosis.Oettingand Stein (1966) also reporton beliefsand atti-
tudes towardmentalillness.In a carefullyreasonedpaper Shiloh(1968)
discussedthe framework of medical beliefsand practicesin the Middle
East. A useful featureof this discussionis his analysis of the way in
whichthe conceptsand practicessubsumedwithinthe Middle Eastern
systemcontrastwith thoseof Westernmedicine.Two recentpapers by
Fabrega (1970b, 1971a) elaborate upon relationsbetween native con-
ceptual traditionsabout illness and Westernscientificmedical knowl-
edge, drawingupon data about ZinacantanMaya of Chiapas. The medi-
cal knowledge possessed by folk medical practitionerand nonpracti-
tionerco-membersis compared in order to clarifyfunctionalcharac-
teristicsof folkmedical care systems.Vogt's (1965) scholarlyarticleon
Zinacanteco souls should be consultedforthe backgroundof medical
beliefs in Zinacantan.His comprehensivemonograph(1969) contains
a wealth of backgrounddata about medical issues in Zinacantan and
should also be consultedfor additional details.
The studyof Pridan and Navid (1967) deals with the problemsof
competingmedical systems.An attemptis made to comparethemedical
knowledge of a group of tenth-gradeEthiopian studentswith that of
AmericanPeace Corps volunteersin relationto a set of commondisease
labels interpretedin termsof given dichotomies (e.g. acute-chronic,
external-internal). As can be expected,large differences were encoun-
tered,both in the kinds of dichotomiesjudged to be relevantby the
two groupsand in the natureof the linkageswithspecifictestdiseases.
The problemofwithin-group variabilityofresponseswas notdealt with,
nor were the implicationsof agreementand variabilitydiscussed. The
paper representsan interesting exploratoryattemptto specifythe rela-
tionshipbetween culturalbackgroundand medical knowledge.How-
ever,the studydoes not address itselfsufficiently to the culturalorien-
tationsof the two groups,and the implicationsof the resultsare not
systematically analyzed.
Morris(1970) comparedhealthcharacteristics and medicallyrelevant
practicesand concerns(e.g. perceived health status,beliefsregarding
nutritiousfoods) in two rural communitiesin Dominica, one of which

176 HORACIO FABREGA,JER.
was describedas less stable and economicallydeveloped. A numberof

differenceswere noted,withhealthproblemsappearingto be morefre-
quent in the less developed community.
Two papers that focused directlyon anatomical knowledge reflect
thepotentialcontribution thatrigorousethnographycan make to ethno-
medical studies.Franklin(1963) providesan interesting ethnolinguistic
analysisof Kewa body parts,withresultsorganizedin termsof levels of
body systems.He also includes some of the conceptionsregardingthe
functionof body parts.Stark (1969) similarlydevelops alternativelin-
guistic strategiesfor arrivingat the semantic dimensionsof various
lexemeswithinthe domainof the body among the Quechua. Linguisti-
cally orientedstudiesof thistypeprovide an excellentbackgroundfor
an analysis of the interpretations that are given to altered biological
processes.The influenceof anatomicalknowledgeon the bodilypreoc-
cupationsand perceptionsof subjects could be clarified.Most ethno-
medical studiesthatfocuson folkmedical issues,and specificallythose
dealing withnotionsof illnesscause, definition, and symptomaticcom-
ponents, exclude the importantdimensionof anatomical knowledge.
Studiesthatexplorehow notionsof body partsand body function(eth-
noanatomyand ethnophysiology)affectthe expressionand definition of
illness would be of significanceto both anthropologyand medicine.
Such studies,in essence,would clarifyhow cultureand cognitioninter-
act with biological processes,and thus the invariantpropertiesof spe-
cificdisease entitieswould be furtherclarified.
IllnessDescriptions
There have been several outstandingdescriptionsand analyses of
what are currently termedculture-specificsyndromesor "folk"illnesses.
Notable are the ones by Newman, Langness, and Rubel. Newman's
(1964) reportof"Wild Man" behaviorin New Guinea containsa wealth
of detail dealingwiththe behaviorof one individualwho demonstrates
featuresof a culture-specific
syndrome.Following this description,he
thenpresentsa balanced evaluationof factorsbearingon the etiologyof
"Wild Man" behaviorin New Guinea. This evaluationprovides a suc-
cinctand scholarlyreviewof the variousfactorsthatare believed to be
importantin the organizationof psychopathologicalbehavior. Lang-
ness's accounts (1965, 1967a) elaborate on the type of behavior de-
scribedby Newman,and providean evaluationof its dynamicsthatin-
cludes referenceto Westernpsychiatricprinciples.His reportincludesa
reviewof similarsyndromesthatappear to bear a structuralrelationship

to the case he discusses,and the implications of the relationshipare
discussed.Rubel's(1964) account,although lackinga detaileddescrip-
tionof thecontentof thebehaviorlabeledsusto,includesan analysis
of thehistory and distribution of thisillnessin HispanicAmerica.To
Rubel,a folkillnessembodiesa changedsociopsychological stateand
symbolizes a culturallysignificantpattern.He seesthesustocomplexas
designating a specifictypeof illness(havingdescribablesymptoms),
and also its explanation. Drawingupon Rubel'sinterpretation of the
severaldifferenttypesofsocialfactors thatmightbearon thegenesisof
thesustocomplex, O'Nell and Selby(1968) conducteda studyin two
Zapotecvillagesthatinvolvedrelating theincidenceofsustoto sex-role
culturalexpectationsand differences in amountofstress.Women,who
are believedto experience considerably morestressthanmen,and,in
addition,are providedfewersanctionedoutlets,tendedto morefre-
quentlyreportsusto.O'Nell and Selbydid not attemptto relatefolk
illnessprevalenceeitherto diseaseproblemsdefinedin termsof alter-
nativeframeworks or to disturbances in biologicalsystems. Neverthe-
less,thisstudymovesbeyondordinary descriptiveaccountsoffolkill-
nessesand makesan attempt to relateillnessmoreincisively to cultural
patterns.
Severaladditionalstudiesof culture-specific illnesseshave empha-
sized differentfacetsof the behaviorsthat signalillnessdiagnosis.
Rodrigue(1963), forexample,reportson the psychological disorder
called lulu,whichis foundin Papua. The manifestations of thisdis-
orderare verysimilarto thosedescribedby Newmanand Langness.
Rodrigue'saccountcontainsa richarrayofclinicalfindings thathe ob-
tainedby examination and history. Thesedata drawattention to motor
disturbances duringtheillnessphaseand also suggestthatchangesin
level of awareness(e.g. confusion, disorientation) are partof thisdis-
order.Koch (1968), also working in New Guinea,describesthecondi-
tiontermednenek.He notessimilartypesofmotorand psychological
abnormalities,and includesconsiderable detailon the behaviorof in-
dividualsshowingthecondition. His reportis notableforitsinclusion
ofmaterialdealingwithfolketiology and treatment. Cawte (1964) has
contributed a balancedreportof theethnopsychiatric concernshe ob-
servedamongtheKalumburupeople in Australia, and has compared
Westernand aboriginalperspectives towardpsychopathology, classi-
ficationofpsychiatricallyrelevant behaviors, andmedicalmanagement.
on thebasisofpredominant
His classification symptom pattern contains
someinsightful observations but is onlyschematically developed;he

does not presentactual clinical material or descriptionsof behaviors

thatserveto indicateillnessand thatunderliethe process of diagnosis.
Hoskinet al. (1969) reportedon theirobservationsofguria,a termused
to designatevarious"shakingsyndromes"thatare foundin New Guinea.
They include in theirdiscussionclinical features,as well as nativebe-
liefsregardingthe source and mechanismof these syndromes.In their
discussion,the relationshipof these syndromesto possession behavior
and to disordershavinga documentedcentralnervoussystemmalfunc-
tion (i.e. epilepsyor seizure disorders) is probed.
Several investigatorsfocusedratherdirectlyon spiritpossession.The
reportof Freed and Freed (1964) containsan excellentdescriptionof
the situationalreactionsto the illnessepisode; theiranalysisis in terms
of the traditionalconceptsofhysteria.Hamer and Hamer (1966), focus-
ing on spiritpossessionin Ethiopia,draw attentionto themanyphysical
complaintsthat are subsumedunder thislabel. They include excellent
data dealing with the family'sreactionto the individualshowingpos-
session behavior,and tend to interpretthe phenomenonin sociopsy-
chologicalterms.Lewis (1966) and Wilson (1967), on the otherhand,
tend to emphasize social and structuralfactorsas causative forcesof
possessionbehavior.The reader wishingto obtain furthermaterialon
possessionstatesis urged to consultthe collectionof papers edited by
Prince (1968), especially the chaptersby Bourguignon,Ludwig, and
Van Der Walde. The firstof thesepresentsa comprehensiveframework
that allows organizingthe large amountof data that has accumulated
about trance and possessionbehavior. The application of this frame-
work,however,mightprove to be problematicin individualinstances,
since thereare no clear indicatorsspelled out that allow reliablydiffer-
entiatingbetweentranceand possession.Ludwig's chaptercontainsan
excellentreviewof the components,native explanations,and probable
etiologicfactorsthatare regularlyfound associated with altered states
of consciousness.Van Der Walde's account reviews etiologicnotions
on the use oftranceas backgrounddata about hypnosis.The theoretical
paradigm of ego psychologyformsthe foundationof his analysis.
The recentreviews by Kiev (1969), Kennedy (in press), and Yap
(1967, 1969) make unnecessaryan elaboratereviewof furthersubstan-
tive workthatrelatesto the culture-specific syndromesas judged from
the psychiatricstandpoint.All of these reviews are extensiveand of
very high quality. The reviewersapproach the examinationof these
syndromesfroma traditionalWesternmedical perspective,thatis, they
demonstratea persistentconcernwith typingdisordersor illnessusing

Westernmedical criteria(i.e. organicvs. psychiatric;schizophreniavs.
depressionvs. hysteria). For certaintypes of questions this approach
is, of course,necessary.However,manydisagreementsbetweenworkers
in thisfieldseem to overemphasizeWesterntypologicalconcernsand
have the effectof clouding what can be a potentiallyimportantarea
of studyforbothanthropologyand medicine(Salisbury1967,and Lang-
ness 1967b). Anyillnessepisode makespossible a carefuldescriptionof
thefactorsleading to therecognitionof an alteredbehavioralor biologi-
cal state,to the illnessbehavioritselfand the mannerof onset,progres-
sion,and resolutionof the illnessepisode, to an assessmentof the con-
tributionof different apparentetiologicalfactors,and to a carefulanaly-
sis ofthemeaninggiventhebehaviorby membersof the group. (A care-
fulinspectionof the ratherextensivereportsof illnessproblemsin vari-
ous cultureswill disclose thatthese ratherbasic ethnographicelements
of illnessepisodes are usually overlooked.) The greaterthe numberof
case analysesof thistype,the morewe will be able to learn about fac-
tors influencingbehavioral reactions.A follow-upof individualswho
have had these reactions,a surveyof the frequencyand distribution
of occurrences,and specificationof the social contextand of how the
behaviordiffers fromotherbehavioralreactionsthatmay or may not be
viewed similarlyby membersof the groupwould allow a betterunder-
standingof the meaning of these reactions.
A reviewof the literaturewill disclose that,in ethnomedicaldescrip-
tionsof illnessfeaturesand illness classification,the moral,social, and
interpersonal dimensionstendto be givenprincipalemphasis.The influ-
ences that bodily manifestationsand changes have in the interpreta-
tion given to an illness episode are slighted.A methodologicalfactor
may accountforthis.In contrastto domainssuch as firewood,the color
spectrum,or botany,which allow the investigatorto presentin an or-
derly manner concretespecimens to the subjects (Berlin, Breedlove,
and Raven 1968, and Metzger and Williams 1966), the investigator
wishingto studyhow illnessis definedand classifiedis forcedto adopt
one of two strategies.He may eitheranalyze subjects' responsesto a
natural occurrenceof a disease (which is problematic,given that ill-
ness attacksare infrequent, judged to representcrises,and regardedas
private) or rely on data derived frominterviewsconducted afterthe
fact. The consequence of these factorsis that it is difficult to obtain
precise and reliable data about specificindicatorsthat underlieillness
definitionand classification.Stated differently, the investigatorwish-
ing to studyhow native subjectsclassifymedical phenomenais usually

constrainedby his generalinability

to have accessto specificand con-
creteinstancesof thisdomain.This constraint mustbe viewedas one
limitationoffolkmedicalstudiesinsofar as itbarstheinvestigator from
preciseempiricaldelimitation ofthisdomain.
A relatedand equallyseriouslimitation of ethnomedical studiesis
thatmedicaldata elicitedand organizedas partof an ethnographic
inquiryare rarelyanalyzedin termsof or withreference to external
systems ofmeaningthatbear directly on the domainunderinvestiga-
tion(Goodenough1957,Pike 1954,and Wallace 1962). This is to say
thatnativemedicalcategoriesand classification schemesare notordi-
narilycomparedin a systematic fashionwithsimilarphenomenathat
are classified
by alternativeframeworks. Attempts to achievethistype
of comparative focushave enabledanswering someof the theoretical
questionsthatare of concernto anthropologists, althoughin each in-
stancethe alternative classificatory
framework (in thiscase Western
medicalknowledge)has been appliedto information generatedfrom
interview data.The itemsclassified,in otherwords,havebeen reports
ofillnessdimensions and notobservablemanifestations of disease(see
forexampleFabrega1971a).Oneconsequence ofanalyzing folkmedical
beliefsexclusively
in nativeculturallogicis thatsomecriticalquestions
thatare of concernto medicalecologistsand populationbiologists
cannotbe meaningfully answered.(See sectionon medicalecologyand
medicalepidemiology in thischapter.)
ContextofMedicalProblemsand MedicalCare
Studiesofthecontext ofmedicalcare,eitherinpreliterate
settings
per
se or in situationsof culturalcontactand culturalchange,have been
numerousduringthe periodof thisreview.Wolff(1965), Weinberg
(1964), Gould (1965), and Soliende Gonzalez (1966) providecom-
parativeinformation abouttheuse offacilities
associatedwithcontrast-
ing medicalsystems. Shiloh(1965) presenteda case studyinvolving
leprosyand itsmanagement amongtheHausa ofnorthern Nigeria.The
nativebeliefsand orientation towardleprosyare firstcontrasted with
thoseof Christianmissionaries who had attempted to treatleprosy.
Then the reasonsforthe successof the government's treatmentpro-
graminvolving Western scientific
methodsarereviewed. The studyrep-
resentsa clear illustrationof how competing medicaltraditions can
interactin a positivewayand lead to thecontrolofa prominent health
problem.In a seriesofpapersMacleananalyzestheYoruba(Nigerian)
traditionalmedicalsystems(1965b,1969), analyzesaspectsof transi-

tionamong the Yoruba in an urban context(1965a, 1966), and focuses
moreintensivelyon the phenomenaof competingmedical systems.Re-
sults (1966) indicate,e.g., that the "emergingmiddle class" does not
respond differently to treatmentof illness than does the group living
in the traditionalYoruba pattern.An interesting findingwas that close
to 50 per cent of the householdsin the traditionalarea relied on native
medicines as a prophylacticand treatmentfor fitsor convulsionsin
children.Press's (1969) studyin Bogota, Colombia, is similarin focus,
and containsa veryuseful analysisof the patternsand implicationsof
dual use of medical systems.It includes a sensitiveawareness of the
expressivefactorsthat play a role in the use of medical care facilities
and personnel.Stanhope's (1968) report,althoughnot concernedwith
medical care per se, is included here because it touches on the theme
of "competition"betweenmedical systems.It is unique in thatit focuses
on discreteillnessconditionsor problemsand describesmodes of treat-
ment.P. Turner (1970) providesa useful additionto the literatureon
the role of witchcraftand quality of interpersonalrelationsin relation
to illness (Chontal Indians).
MedicalTreatment
The treatmentof illnesshas continuedto receive a great deal of at-
tention.The analysisby Frank(1963) ofthefactorsthatplay a role in the
attemptsat the modificationof behavior
degree of success of different
factorsrepresentsa classic. He reviewssuch
by social and interpersonal
seeminglydiversesituationsas religiousconversion,psychotherapy, cur-
ing ceremonies,and attemptsat thought reform in order to develop a
framework forexplainingbehaviorchange. Frank givesparticularatten-
tion to emotionalfactorsin his discussion (i.e. factorsinvolvinghope,
faith,self-worth).His chapteron religioushealing containsa number
of excellentinsightsand includes a discussionof the probable physi-
ological consequencesof curingceremoniesthatcan affecthealthstatus.
The chapterby Kiev in the book he edited (1964) also containsa use-
ful summaryof the many issues that influencethe success of medical
treatmentpracticesand is more centrallyfocused on specificproblems
bearing on folk "psychiatric"treatment.The Kiev collection contains
several illustrationsof how psychologicalfeaturesof treatmentcere-
monies promotehealing (e.g. Murphy,Fuchs, Madsen). The studies
by Holland and Tharp (1964), Balikci (1963), and Kiev (1966) are in
the same tradition.The paper by Kennedy (1967) deals more directly
withpsychologicalillnesses,and his recentgeneraldiscussionof "primi-

tive"psychotherapies (in press) is verycompleteand shouldbe con-

sultedfordetailsof thisparadigmforexplaining treatment. Osborne
(1969) studiedthevillagepsychiatric treatment programs amongthe
Egba-EgbadoYorubapeople.The twovillagesthathe studiedareused
as treatment unitsby hospitalsin thenearbyarea.The socialstructure
and patternsofinterpersonal relatingin the community are discussed
in termsof theirfacilitativeeffect on thetreatment program.
A numberofstudieshavefolloweda different approachto explaining
folkcuring.Romano's(1965) description ofcurersand healingin south
Texas showsa sensitivity forsocialfactors:he anchorshis analysisin
a "healinghierarchy" thatincludesfamilyand friendsof the person
needinghelpand proceedsto elucidatefeatures ofhealershavinggreat
renown.Maclean's(1965b) reportdescribesin somedetailthecuring
personnelin Ibadan,together withtheirmethodsof approach,and is
notableforitscomprehensiveness. Nash (1967) providesa carefulde-
scriptionof curing,beginning withdiagnosis,throughthe ritualsand
practicesthatare believedto constitute thetreatment. The description
is accompanied bya presentation ofthe"logic"or theory ofillnessthat
rationalizestheprocedures thattakeplace in thecure.Buchler(1964),
in examining medicalcarepractices, offersdata in supportofthesym-
bolicimportance ofthephysicalformofthemedicineusedintreatment.
Parrott(1970) studiedtheremedies andtheirpresumed modeofaction,
in northern Nigeria.The clinicalsituation occasioning theuse ofreme-
diesand thenativemannerofpreparing theseremediesare briefly dis-
cussed.Fabrega (1970a) examinedthe processof folktreatment in
Zinacantanand gave particular attentionto theimplications of t-hein-
teractionbetweenhealerand clientforthe treatment process.Lieban
(1965), working in a cityin thePhilippines, studiedthe activities of
theshamanfromthestandpoint of socialcontrol.The maintenance of
shamanism was explainedby Liebanas relatedto weaknesses and limi-
tationsin theformal systemofsocialcontrol, particularlyin thearea of
maintenance of property rightsand maritalobligations. Cunningham
(1970) described a variety ofthecharacteristicsofmedicalcareinrural
Thailand.He includesin hisreporta listofthetypesoffolk-andWest-
ern-oriented personnel, and givesprincipalattention to the "injection
doctors."He relatesthe proliferation of thesepractitioners to social
changesthathavetakenplaceinthearea,inparticular thegap invalues
and orientationsbetweenvillagersand official healthpersonnel and the
existenceofan opendrugmarket.
An unfortunate deficiency of moststudiesof folktreatment is the

regularabsenceofdata regarding developmental aspectsoftheillness
and itstreatment, especiallyofcase studiesin depth-"illnesscareers,"
so to speak.Rigorousstudiesofhowfolkmodesoftreatment linkwith
Westernmedicalmodesare neededso thata widelyapplicablemodel
ofmedicaltreatment canbe constructed.
Two papersdealingwiththemedicinedanceofthe!KungBushmen
deservemention fortheirrichnessand elegance.Marshall's(1969) con-
tainssomedata dealingwithmedicalbeliefsand practices, and thera-
tionaleofthecuringfromthestandpoint ofmedicalhappenings is more
explicitlydeveloped.Lee (1968) focusesmoredirectly on thepsycho-
logicaland behavioralactionsand implications of the participantsin
thecuring.Lee is moreinterested in examining how thecuringdance
affectslevelsof awarenessand consciousness. Bothpapersare models
ofethnographic analyses;medicallyrelevantaspectsofculturally orga-
nized humanactivityare depictedrichly, withattention givento the
situationsthatoccasionthecuringdance,to theformand structure of
curingactivity,to thegeneralmeaningand value ofthedance,and to
its apparentbenefitor function forthe group.
PersonalCharacteristics oftheMedicalPractitioner
Moststudiesdealingwithshamanistic medicalpractitioners havefo-
cusedon personality attributesgenerally,and morespecificallyon the
healthstatusofshamansviewedfroma psychological standpoint. Few
researchers have dealtwiththeshamanas a provider of medicalcare,
i.e. as a roleplayerdifferentiated
onthebasisofhisknowledge ofillness,
remedies, orthediagnosistask,ofhismannerofevaluating clients,etc.
An exceptionto thispsychological approachis demonstrated in the
studybyMetzgerandWilliams(1963). In a concisereportthey"exam-
ine theroleofthecurer,placingparticular emphasison thecharacter-
isticsand performances whichnotonlydefinetherolebut whichalso,
in theirinternalvariation, are the basis forevaluationof curersand
selectionof one curerratherthananother"(p. 216). Usingrigorous
methodsof elicitation, theyreporton themethodof diagnosis, these-
quenceofperformances in curing,thesocialevaluationof curers,and
theconditions and procedure forseekinga curer.
Margetts(1965) extensively reviewsthepracticesof thetraditional
Yorubahealers.He does not give attention to the underlyingbeliefs
thatorganizemedicalcare,but stressesthe personalistic motivations
and intentions ofthehealers.Fabrega (1970b), in contrast,compared
themedical-knowledge base ofa groupofshamansand nonshamans in

184 HaORACIOFABREGA,JR.
Zinacantanand foundno differences whensymptomatic components

ofvariousillnesseswereused as referents. However,whendimensions
of illness(i.e. notionsinvolvingcause, severity, mode of treatment)
werefocusedupon (Fabrega 1971b), he observedgroupdifferences
involvingcontentand responsetendencies.Shamanstendedto state
morefrequently thatdeitieswerethecause ofillnessand also thatill-
nessesweretreatableand,specifically, bynativepractitioners. In addi-
tion,therewas evidencethat,as individuals, shamanstendedto dem-
onstrate greaterconsistency withthemselves acrosstheseriesof ques-
tionsthatwereasked.The paperby Handelman(1967) presents a life
history studyof a Washoshaman,demonstrating his role as an inno-
vatorof curingproceduresunderacculturative stress.This studyby
Handelmanhas a numberof dimensions and makesa significant con-
tributionto cultureand personality studies.
Employing a uniqueresearchplan,CarlosCastaneda(1968) studied
undera Yaqui shaman,or manofknowledge, in an attempt to under-
standtheimplicit rulesthatgoverntheactionsofthecurerin thatcul-
ture.The bookis presented as an essayinwhichtheauthor, largelyun-
knowing, is guidedthrough a seriesoflearningexperiences underthe
tutelageoftheshaman.The essay,or "data,"is reportedas it is given,
thusadoptingan emic perspective. The rulesthatare extractedare
presentedfromtheperspective of the outsideobserver, fromthe etic
perspective. It is thusan interesting combination of perspectives in
anthropological research. An essayby Murdock(1965) concentrates on
thepsychological aspectsof shamans,and uses a broadhistorical and
culturalapproach.Thispaperis notableforthewealthof data it pre-
sentson beliefsaboutdiagnosisand curingpowers,and abouttherole
of the shamanin the community. Lebra (1969) used personalinter-
views,observation ofhealingsessions,and projective instruments in his
studyof the shamanin Okinawa.He notedconsiderable evidenceof
psychological intheseindividuals
difficulties and,likeSilverman (1967)
and Sasaki (1969), goes in considerabledetail intothe recruitment
phaseoftheshaman'scareer.Osgoodet al. (1966) presented extensive
information on thecharacteristicsoflaymidwives in easternKentucky.
Personaland socialfeatures of one maleand ninefemalepractitioners
weredescribed, including theirbackground, experience, formof train-
ing,and the characteristics of theircurrent practice.This articlealso
containsa usefulanalysisofsocialand structural aspectsofthesystem
of medicalcare of theregionthatmaintains the activity of midwives.
Tenzel (1970) studiedthe characteristics of shamans,includingthe

basis of theircuringpowersand theirassumptions about healthand
illness,andtherelation ofshamanism totheillnesssusto.Allindividuals
thathe examineddemonstrated evidenceof physicaldisease,and he
emphasizesthe need forcautionwhengeneralizing about the nature
and processesunderlying commonfolkillnesses.The papersby Boyer
et al. (1964) and Boyer(1964) employa psychoanalytic framework
and discussintrapsychic aspectsof Apacheshamans.The recentem-
piricalpaperby Fabregaand Silver(1970) manifests a relatedclinical
concern, althoughtheexigencies ofmedicalcareand practicethatbear
on theroledutiesoftheshamanare takenintoaccountin theanalyses
ofresponses to a projectivetest.
V. Turner's accountsofpractitioners in Africa(see forexample1967,
1968) need to be carefully consultedin anyattempt to broadlyunder-
standtheactivitiesofthepractitioner as theserelateto treatmentsitua-
tions.In contrastto thetypicalpsychodynamic emphasesthatare com-
monin mostaccountsofshamanistic behavior, Turneremphasizes how
the shamancreatively linkssocial processesand situations withthe
multivalent meaningsofculturally relevantsymbols duringhisattempt
to meethis obligations and responsibilities.
Ethnomedical Studies:Summary Statement and Critique
Ethnomedical studiesappearto be guidedby thefollowing dimen-
sionsofillness.(1) Defining Anillnessinvolves
characteristics: a change
in thestateofbeing(e.g. feelings, thoughts, (a) which
self-definition)
is seenand labeledas discontinuous withroutineeveryday affairs,(b)
whichis believedto be causedby socioculturally definedagentsor cir-
cumstances, and (c) forwhichthereare culturally specificformsof
treatment.Anexamplemightbe an illnessdue topunishment bysuper-
naturalagenciesforfailingto complywithcertainsocio-moral norms
thatrequireX kindofherbsorY typeofcuringceremony. (2) Indicat-
orsofillness:Principalattention is giventochangesinbehaviors, togen-
eralbodilycomplaints (e.g. nervousness,weakness),and to verbaliza-
tions (involvingbeliefs,feelings,impulses,etc.) regardingthe per-
ceivedchangein identity that,it is frequently
said,signalsand repre-
sentstheillness.Giventhismodelor definition theconcern
of"illness,"
ofinvestigators seemsto be to explaintheillness-itsgenesis,mecha-
nism,descriptive features, treatment, and resolution-asan eventhav-
ingculturalsignificance.
An examination ofthepreceding modelofillness(or framework with
whichto analyzeinstances ofillness)shouldmakecleartheaffinity that

"medicalanthropology" hasalwayshad withpsychiatry. Mostindicators

of psychiatric diseasesinvolvebehaviors,feelings,beliefs,modes of
thinking, etc. Mostpsychiatrists willacknowledge thatsocialand psy-
chologicalfactorsare important in theetiologyofpsychiatric diseases,
and featuresof thediseaseare examinedby themand givenmeaning
and significance in psychological and sociobehavioral terms.Last, an
important modality oftreatment ofpsychiatric diseasesis psychothera-
peuticand/orsociointerpersonal. Thus the significant clinicalfeatures
and dimensions of psychiatric diseases(e.g. cause, form,treatment)
involvedata and happenings thatculturalanthropologists have always
dealtwithcomfortably. To be sure,thisinterest on thepartofanthro-
pologists inclinicalpsychiatric concerns hashad effects.Prominent char-
acteristics ofAmerican psychiatry todaymustin factbe seenas a con-
sequence of the incisivecontributions of Americananthropologists.
(See Weakland1968foran elaboration on thispoint.)The long-stand-
ing close associationbetweenthesetwo disciplines has had the effect
of imparting a distinctorientation to ethnographic studiesof medical
problems, namelythatinstancesof illnesses(i.e. "folkillnesses")have
been regardedas culturally patternedsociopsychological happenings.
Stateddifferently, instances ofillnesshavebeendescribedand analyzed
in largepartas iftheywere"psychiatric."
The oftentoo uncritical adoptionof the (Western)framework of
psychiatry in nonliterate settingsby culturallyorientedanthropologists
has tendedto obscuretheinfluences thatbiologicalcomponents have
on (culturally defined)illnesses.Specifically,ithas notprovedpossible
to determine whatkindsof physiologic or otherbiologicchangesare
organizedsystematically intoculturally and sociallypatterned illnesses
andwhichprocesses tendtobe associatedwithlessculturally intrepret-
able illnesses.This one-sidedview of illnessseriouslyconstrains the
framework neededto analyzemedicalprocesses in the fieldand has
thereby limited thecontribution thatanthropologists havethusfarmade
in thisarea ofstudy.
It is regrettable thatmanyculturalanthropologists interested in eth-
nomedicine havenotheededtheadviceofMead (1947), and the exam-
ple ofWallace (1961),in approaching thestudyof illnesswith a frame-
workthatincludesbothphysiological processesandbehavioral changes.
Thisperspective is also illustratedin papersby Rohrl(1970), Mazzur
(1970), and Katz and Foulks (1970). Givena concernwithbehavior
and itsorganization and a desireto probemedicalissuesin an incisive
manner,an awarenessof the as yetlargelyuntappedbiologicalcom-

1MICAL ANTHROPOLOGY 187
ponentsofdisease would appear mandatory.The vocabularyofWestern
scientificmedicine is replete with linguisticforms(e.g. pain, nausea,
onset,natural history,weakness) that require examinationand inter-
pretationby means of a comparativeorientationtoward medical hap-
penings.Ethnomedicalinquiriesusing structural-linguistic methods,an
ecological approach,or a processualparadigm (to name a few) would
serveto enhancegreatlyour understandingof humanbehavior,medical
problems,and theirinterrelation. If medicallyrelevantbehaviors are
linked in a systematicfashionwith even rathergeneral biological par-
ametersof illness,it should be possibleto constructa typologyof illness
that bridges the socioculturaland biomedical framesof referenceand
that in timemightallow anthropologists to develop models of medical
care.
An examinationof the literaturein ethnomedicinereveals that in-
stances of illness or disease are usually handled analyticallyin one of
fourways. (1) An episode of illnessindicatesa point or area of stress
and dysfunctionin the socioculturalsystem.This dysfunction(i.e. ill-
ness) is itselfviewed as determinedby psychoculturalfactorsor as sto-
chasticin the sense of representing an obtrusionof "natural"forces.At
anyrate,thisdysfunction in thesocioculturalsystemthenprovidesan op-
portunityforspecificinstitutions and/orotherculturallypatternedfac-
torsto bringabout a reparationor controlof the situation.(2) An illness
episode is suffusedwith heightenedemotionand concern and conse-
quently provides a focus for the demonstrationof how religious and
other "supernatural"ideas get expressed in symbolicactions,rituals,
practices,etc.,thatexercisepowerfulinfluenceson the behaviorsof the
sick one and his family.Althoughthisframeof referenceis not exclu-
sive of the "functional"one illustratedin (1) above, it is analytically
distinguished,since the main effortof the ethnographerappears to be
devoted to processual and symbolicissues. (3) An instance of illness
shows how socioculturalpatterns"shape" the expressionof disabilityit-
selfas well as generalaspects of illnessand medical care (regardlessof
whetherthe medical occurrenceis determinedor stochasticas in (1)
above). Thus, a largelydescriptiveinterestoftenseems to motivatethe
anthropologists.(4) Episodes can bringabout profoundbioculturalin-
fluencesin the culturalgroup (see nextsectionon medical epidemiology
and medical ecology). Regardless of which analytic frameworkis
adopted,it is usuallythe case thatthe illnessepisode itselfis not differ-
entiatedin such a way thatit allows othersto build on the impressions
and insightsgained in the field.Briefly,the illness episode is treated

eitheras a specific butratherabstractbiologistic category(not articu-

latedin a behavioralsensewithculturalprocessesand happenings), or
as a generic(and global)culturally organizedandtemporally patterned
occurrence. The latterformalization createstheillusionthatall illnesses
are similarly patterned and have theculturalsignfficance thattheeth-
nographerattributes to the one examined.Illnessepisodes,in other
words,obviously varyaccording to typesand modesofonsetand reso-
lutionand accordingto socialand temporallocations;and theyoccur
in individuals(or family units)characterized by particularhistories.
A
realisticappreciation of thereciprocalinfluences thatculturalfactors
have on illnessand diseaserequiresa morefine-grained depictionof
medicalhappenings.
Whatis notaltogether clearis whattranspires situationallypriorand
subsequentto clearlydefinedillness-treatment episodes:the sequence
ofevents(orprocesses)thatprecedethe"social"definition ofillness;the
earlybehavioral manifestations ofillnessandtheactionstakentorelieve
them;and thedurationand progression ofphysiologic symptoms. The
past social and medicalhistoryof the personexperiencing the early
manifestations ofillnessmustalso be specified. Analysesofthesevari-
ousissueswould,e.g.,clarify whatfactors illnessoccurrences,
precipitate
and answerquestionscentering on thekindsofsocialand bodilymani-
festationsthatpersonstolerateor do notact upon.
Similarly,it is important to clarify whattranspires aftera curingor
treatment procedure.Some itemssuggestthat as a person'sillness
abates,previously ruptured(or problematic)social relationships are
reestablished, leadingto a diminution in tensions.Muchmorelikely,of
course,is thatsomeill personscontinue to deterioratemedically, others
remainunchanged, and stillothersbeginslowlyto improve. In thiscon-
text,thelinkagebetweensociocultural and biologicfactors needsto be
specified.Similarly, regardless ofwhatdoes followa treatment proce-
dure,includingdeath,it is clearthata socialprocessis involved.It is
notablethattherecentanthropological literaturecontainsfewdescrip-
tiveor theoretical statements regarding the processesthatlead up to
and followa "natural" deathin a particular socioculturalunit.
If theprecedingtypeof information is generated,together withan
accurateportrayal of themeaningsand interpretations givento these
happenings, thenit shouldbe possibleto beginto construct a broader
pictureofthewayinwhichsociocultural processesaffectand areaffect-
ed by biomedicalprocesses.Muchof theliterature suggeststhatmost
illnessepisodesare simplyanothertypeof criticalincidentin thelife
of a family, the explanation of whichfollowsfromthe current status

and degree of social integrationof the familyor sick person.The data
necessaryto determineclearlyifthisis the case are sadly lacking.These
issues, of course,take on a more diversifiedsignificancewhen a situa-
tion involvingthe contact between cultures(and contrastingmedical
traditions)is made the settingfora study.The glossaryof termsat the
end of this chapter may have cross-culturalidentification utilityand
may therebyprove helpfulfororganizingworkand impressionsin the
field.
To a verylarge extent,topics dealt with in ethnomedicinehave not
been subject to precise definition, systematization,testing,subsequent
refinement, and elaboration,which,in time,leads to the accumulation
of knowledgevaluable to anthropology.A place to begin mightbe in
the constructionof a typologyof illnesses.In evaluatingor coding an
instanceof illness,the followingfactorsmightbe included: (1) levels
or degreesof behavioralconstraints(e.g. bed confinement, confinement
to house; (2) levels or degreesof role constraints(e.g. inabilityto per-
formrole of provider,father,housewife); (3) durationof variousstages
of illness (i.e. timein days); (4) numberand type of relativelyvisible
behavioraland biological symptoms(e.g. vomiting,assertionsof moral
inadequacy, diarrhea,complaintsof pain, degree of social discredita-
tion, change in attitude toward other group members,hotness and
sweatiness,confusion); (5) mode of onset of symptoms(e.g. which
were firstsymptomsor indicators;whichones followed;when was pres-
ent disabilityreached); (6) range of possible treatmentmodalitiesthat
are occasioned by the illness; (7) strategyof treatment(i.e. which
treatmentmodalitiesare triedfirst, whichfollow); (8) presumedsources
or typesofultimatecauses thatare attributedto the illnessin itsvarious
stages; finally,(9) what are the consequences of the illness episode or
illness chain on the power alignmentsin the immediategroup and on
the statusof the sick person if he survives.The precedingdimensions
are tentativelyoffered,and otherscould obviouslybe developed.
The contextwhereinillness occurs,of course,may affectthe values
thateach of the precedingdimensionsof illnesstake on. Consequently,
it would be importantthat (antecedent) unique or salient situational
factorsaffectingthe immediateand extendedgroup be documentedif
these exist.This in time would allow specifyingwhich dimensionsof
illnessare situationallylinkedand whichones are relativelyindependent
or durable over time (i.e. trans-situational).
Anthropology(and social science generally)standsto gain by devel-
oping a behavioral frameworkfor examiningillness.By coding illness
and disease-relatedbehavioral responsesin a fashionthat preservesa

measureof culturalspecificity at the same timethat it allows forsome

abstraction,an opportunity is providedforconstructing a model of de-
velopmentalmedical care. Other parametersof interestto anthropol-
ogistsmightthus be linked analyticallywith the medical system,the
latterimmersedsecurelyin cultureand behavior and not in the tradi-
tional biologisticconceptionof disease and medical care. Glick (1967)
has alreadymade an excellentbeginningin thisdirectionin his portrayal
and analysisof medicinein the New Guinea highlands.The papers by
Press (1969), Schwartz(1969), and Fabrega (1970a,b, 1971a) contain
observationsand formulations that bear on this point. The papers by
Devereux (1963) and Hallowell (1963) containusefulobservationsand
inferencesregarding illness definitionand behavior, although they
largely employ a psychiatricframework.Weaver's (1970) interesting
studyinvolvingtheuse ofhypotheticalsituationsin a studyofillness-re-
ferralsystemsseems to be motivatedby an analogous concernand illus-
tratessome of the practicalimplicationsof the analysesunder consider-
ation. The classic studies by American sociologistssuch as Freidson
(1960), Mechanic (1962), Suchman(1965a-c, 1967),and Zola (1966) con-
tain excellentanalysesof illnessbehaviorin Westernindustrializedset-
tingsthatwould allow sensitizinga model ofillnessbehaviorand medical
treatmentto elementsthatare likelyto contrastin different sociocultural
units.The papers by Kasl and Cobb (1964, 1966a,b), and chapterfour
in Coe's (1970) book containanalyticschemesthatrelyon the preced-
ing body of sociologicalworkand should be consultedfordetails.
MEDICAL ECOLOGY AND EPIDEMIOLOGY

Statement
Introductory
The chapterby Scotchin the 1963 editionoftheReview has helped to
make the domain of medical epidemiologya legitimateconcernof an-
thropologists.This is not altogethersurprising,given the broad focus
of anthropology and its concernwiththe examinationof themanyinter-
relatedfacetsofhumanadaptationand behavior.Anthropology and epi-
demiologysharein theattemptto specifyhow diseases distributein rela-
tionto socioculturalas well as biological factors(see Damon 1964). In
the years since Scotch'sreview,a fieldof inquirythatis generallyiden-
tifiedwithpopulationbiologyand humanecologyhas been increasingly
linkedformallywith"medical anthropology." In thissectiontheoretical
developmentsin thisfieldare brieflydiscussed. This will lead to a re-
view of studies dealing with the medical problems of contemporary

preliterategroups and those of early man. In general, an ecological
frameworkis employed in these studies,and problemsof disease are
examinedfromthe standpointof biological and culturalevolution.The
natureof the fielditselfand the fact that excellentreviews of studies
in thisarea have recentlyappeared means thatit will not be necessary
to referin detail to substantivefindings.
In this section,medical epidemiologyis viewed as the studyof the
distribution of disease (definedin termsofWesternmedical categories)
in relationto physical,biological,or socioculturalfeaturesofthe environ-
ment.Most such studies are conductedin industrializedsettings,tend
to employ "traditional"linear-deductiveand quasi-experimentalde-
signs,make use of surveymethodsand data fromagency or hospital
records,and aim to develop and refinehypothesesabout the causes of
disease. The literatureon epidemiology,even the portionof epidemi-
ology givingemphasisto socioculturalfactorsor to the medical prob-
lems of preliterategroups,is veryextensive.Only a selected portionof
thisliteraturewill be reviewedhere. Similarly,limitationsof space pre-
clude offeringa critique of the methods employed or analyzing the
validityof the findings."Medical ecology"will be viewed as the subset
of medical epidemiologythat addresses itselfto additional questions,
such as those dealing with population biology and human evolution.
Medical studies that can be termedecological are usually conducted
in preliteratesettings.The natureofthephysicaland geographicsetting,
the habits of the residentsof these settings,as well as the problems
being studiedoftenrequirethata moreholistic,multilevel,and explora-
toryorientationbe adopted in these studies. See for example Tromp
(1963), Sargent (1966), Dubos (1968), May (1960), and Shimkin
(1970). Thus,inwhatI shalltermmedical-ecologicalstudies,such issues
as the diet of the subjects,theirenergyexpenditure,theirblood types,
and antibodytitersare given attentionas well as apparent and mani-
fest health status; similarly,demographiccharacteristics(manner of
formingsexual unions,group composition,patternof group dissolution,
etc.) and featuresof the environment(e.g. climate,animal life,com-
positionof flora) thataffectadaptationallevels,healthstatus,and social
organizationmay be emphasized.As can be seen, then,a broad frame-
workis used to evaluate medical problems.It needs to be emphasized,
however,that the ecological frameworkor approach has always been
an inherentfeatureof medical epidemiology(see Gordon and Ingalls
1958,Rogers1962,Kartman1967,and MacMahon and Pugh 1970), and
thatdistinguishing betweenthesetwo approachesis somewhatarbitrary.

Studies
Generaland Theoretical
A numberof generalreviewsand theoreticalarticleshave appeared
since 1963 dealingwiththe influencesand implicationsof disease (con-
sideredas a biologicalphenomenon)in non-Westerngroups.Two early
papers by Polgar (1963, 1964) focused in a very general way on the
probable medicalproblemsthatcharacterizedhumangroupsduringthe
various stages of culturalevolution.In these papers the influenceof
living conditionsgenerally,and specificissues such as physical and
faunal characteristicsof the environmental setting,size and densityof
humangroups,permanenceofhabitationsites,and behavioralpractices,
on typesand patterningof diseases were discussed.Hughes (1963) re-
viewed in more detail the kindsof behavior and life situationsin pre-
literategroupsthatare relevantto healthstatus.The paper did not ad-
dressitselfto particularhistoricalperiods,but merelydiscussedgeneral
issues. The effectsof magico-religiousdevices, empiricalpreventives,
personalhygienehabits,cosmeticand mutilationpractices,housingand
settlementpatterns,mannerof waste disposal,food habits,etc., on the
prevalenceand persistenceof disease in human groupswere discussed.
An attemptwas made to describethe mechanismwherebythesefactors
affecthealth status.In an elegant and concise manner,Dunn (1968)
has focused on the typesof medical problemsof hunter-gatherers. He
firstpresentsthe sourcesof data thathumanbiologistscan use to evalu-
ate health statusin prehistorichunter-gatherers. Then he uses current
literaturedealing withhealthproblemsof contemporary groupsto dis-
cuss the mortalityof hunter-gatherers. He gives attentionto the influ-
ence of ecological diversityand complexityin the attemptto explain
rates of parasiticand infectiousdiseases. This chapter is very useful,
since it addressesitselfsystematicallyto a varietyof summaryproposi-
tions about biomedical featuresof hunter-gatherers (e.g. frequencyof
starvation,traumaticdeath rates). Gray (1965) reviewedmedical and
relatedanthropologicalresearchin Africa,and gave particularattention
to the principalphysicalhealth problemsof the region.A segmentof
the succinctlywrittenpaper by Goldstein (1969) reviews in a clear
mannerthe recentliteraturedealing withpathologicalfindingsin skel-
etal remains,and anothersegmentfocuseson diseases thatare encoun-
tered in living"primitivesocieties."
General analyses and reviewsof the literaturedealing with the dis-
ease problemsof earlierhumangroupsand civilizationshave been plen-
tifulduringthe timeperiod under investigation.Brothwell(1963) and

Wells (1964) are good generalintroductory books in the fieldof paleo-
pathology.Kerley and Bass (1967) provide in briefcompass a state-
mentof the scope, methods,and problemconcernsof thisfield.Jarcho
(1966) has editeda collectionof essayson selectedproblemsin thefield
of paleopathology; it also contains chapters dealing with data from
recent excavations,and othersthat review the recentphysiologicand
allied researchfindingsin osteologythat may have potentialvalue in
furtheranalyses of skeletalremains.The book by Ackerknecht(1965)
reviewsclinicalfeaturesand backgroundknowledgeof a numberof im-
portantdiseases that have played importantroles in recorded human
history.He describes the natural history,manner of spread, conse-
quences, and eventual controlof such diseases as plague, typhus,and
yellow fever.Historicalaspects and the geographicdistributionof the
diseases are particularlystressed.The new editionof Burnet's (1966)
classic book shouldbe consultedforrelatedanalysesof importantinfec-
tious diseases. This book focusesincisivelyon immunologicalaspects of
thesediseases,and theauthoremploysa distinctly ecologicalframework.
The Brothwelland Sandison (1967) volume containsgeneral sum-
maries of the literaturedealing with the medical problemsof ancient
populationsand of preliterategroups.This book representsa summary
and assessmentof the field of paleopathology.The chapters cover a
numberofissues-general systemicmedical diseases,diseases caused by
specificmicroorganisms, congenitalanomalies,arthriticproblems,the
practice of trepanation,etc. The bibliographiesassociated with these
chapterstendto be extensive.The book should be consultedby anyone
interestedin capturingthe scope and elaboratenessof thisfieldof activ-
ity.The publicationsofCockburn( 1963,1967,1971) are relatedto those
discussed here,and deal additionallywith a more specialized aspect of
the problem,namelythe potentialof thisfieldto contributeknowledge
about human evolution.Cockburnis interestedin the distributionof
particularparasitesand microorganisms in primatesand man and uses
knowledgeabout thisdistribution to clarifyissues of man'sphylogenetic
relationshipto otherprimates.The historyand evolutionof infectious
diseases,particularlythosethathave affectedman,receiveemphasis.
Quite frequently,the medical diseases found in nonhumanprimates
receive particularattention,since the resultingpicturebears on ques-
tionsof evolutionas well as on the potentialof transmission to humans.
However, the problemsinvolved in interpreting findingsdealing with
infectionsin nonhumanprimatesare numerousand infrequentlydis-
cussed. The workof Dunn (1965, 1966, 1968, 1970), who was already

citedwithregardto healthproblemsofhunter-gatherers, also deals with

the generalquestionof the distribution of disease and parasitesin sub-
humanprimates,and theirimplicationsforissues of humanbiology.In
his papers he discussed criticallythe problemsof interpreting data re-
ported by others.In addition,his papers should be consulted for an
appreciationof the logic and strategyof analysesin thisfieldas well as
fortheirsubstantiveinformation. In his essay dealing withthe antiquity
of malaria,forexample,he summarizesthe literaturedealing with the
distribution of thisdisease, and thencriticallyexamineshypothesespur-
portingto explainthisdistribution.
The paper by Otten (1967) reviews in a quite thoroughand very
criticalmannera portionof the literaturedealing withthe relationsbe-
tween man (viewed in termsof the immunologicalpropertiesof his
blood-groupantigensand sera) and microbialagents capable of caus-
ing clinicalinfections.The problemsdiscussedin thispaper are central
to issues such as human evolution,population stability,and the influ-
ence of disease in recordedhuman history.This is the case because it
focuseson ratherbasic biological characteristics thatinfluencethe rela-
tivevulnerability of man to infectious-disease agents.She feelsthatthe
literaturedoes notsupporttheclaimthatthe distribution ofABO blood-
group frequenciesis related to the possible selectiveactionsof specific
infectious-disease agents.She discussesthe influencethat antibodyfor-
mation in various parts of the body can have on the developmentof
infectiousdiseases, and raises the question whetherABO blood types
maycreatedifferent susceptibilities to intestinalmicrobiota.The book by
Livingstone(1967) is an authoritativework that deals explicitlywith
the frequencyand distribution of abnormalhemoglobinsin population
groups; clinical aspects of disease in specificgroups,however,do not
receive much attention.Wiesenfeld's (1967) paper, which also deals
with hemoglobinopathies,is not a review but representsan original
analyticcontribution. It is includedheresince it also deals withrelations
between man and disease and employsa bioculturalevolutionaryper-
spective.In thispaper Wiesenfeldfirstreviewsearlierworkfocused on
malaria and siclde-cellanemia (Livingstone1958), discussingtherecip-
rocal influencesbetween the developmentof agriculturepractices,the
differenttypesofmalaria,and gene-poolchanges.The questionis raised
whetherdifferent agriculturalsystemshave different effectson thedevel-
opmentof malariaand the sickle-celltrait.By drawing on data fromthe
"World EthnographicSurvey,"Wiesenfeldsupports the claim that the
developmentof a particularagriculturalsystem(termed Malaysian) is

bound to ratherspecificchanges in the gene-poolsof populationsusing
this system.The feedbacksbetween socioculturalhappeningsand bio-
logical changes are seen as allowing population groups to apply and
extractenergymore efficiently froma particularecosystem.Hudson's
(1965) account of how treponematosishas accommodated to man
throughouthis social historyhas a narrowerscope, but it affordsan
illustrationof how disease, culture,and environmentare believed to
interact.Treponemal infections,which many view as producingsepa-
rate and distinctdisease "types"each caused by a "different" type of
treponemalmicroorganism, are described by Hudson as specificout-
comes of the interplaybetween social practices,climatic conditions,
degrees of endemicity,and essentiallyonly one type of pathogenic
microorganism. In developingthisanalyticpositionHudson reviewsthe
literatureand discussesresultsof his earlierwork.
In a series of publicationsAlland (1966, 1967, 1970) has discussed
froma theoreticalstandpointthepotentialinfluencethatstudiesin med-
ical anthropologycan have in the study of human adaptation. In his
recentbook (1970) Alland develops in some detail theview thatculture
is an adaptive response to environmentalpressures,and emphasizes
that,as man changeshis environment throughthe adaptive mechanism
of culture,this changed environmentthen acts as a selectiveagent on
man's physicalstructureas well as on his behavior. The effectiveness
of adaptive traitsmustbe measuredin relationto increasesin carrying
capacity and concomitantincreases in population. Within this frame-
work,the epidemiologicalpatterns,whichvaryamongpopulations,pro-
vide interesting materialforthe analysisof the adaptive process. Any
change in the "behavioral system"is likely to have medical conse-
quences, and, in addition,induced or naturalalterationsin the environ-
mentalfieldprovidenew selectivepressuresrelatingto health and dis-
ease, which must be met througha combinationof somatic and non-
somatic adaptations.Alland discusses in some detail the relationships
among a range of biological and culturalphenomenathat affecthealth
and disease, focusingon infectiousand parasitic diseases, nutritional
disorders,and stress.Alland suggeststhat a game-theoretic framework
can be used in these studies,a game in which the participantsinclude
a populationand an environment, the lattercomposed of specificflora,
fauna,and also the set of "diseases"thatare endemicin the area. From
the standpointof the population,economicexploitation,efficiency, and
population growthserve as indicatorsof gain. The fact that various
diseases are endemic in an area means that population groups must

overcomehealth hazards (the potentiallosses of the "game") in order

to persistand grow. Alland proposes that ethnomedicalpracticesand
otherculturalpracticesand values that affectmorbidityand mortality
be examinedfromthispopulationstandpoint-specifically, what "prac-
tices"promoteadaptationand which ones hinderit. Alland emphasizes
thatfunctional(and expressive)values thatappear to inherein various
ethnomedicalor other cultural practices must be analyticallydistin-
guished fromthe potentialbiological consequences (vis-a-vis disease
distribution)thatthe practicescan have on the group.His fieldexperi-
ence in Africasuggeststhat seeminglyunimportantculturalpractices
(some of whichmay have nothingto do withmedical issues as defined
in the group) may neverthelesshave major influenceson the spread of
disease withinthe group and ultimatelycan be expected to affectthe
populationstructure.This book mustbe seen in the contextof the fer-
ment in the field of human ecology generallyand, more specifically,
under the rubricof "culturalecology." Its contributionlies in that it
reviews a numberof ideas and studies fromdiverse fieldsbearing on
the phenomenaof disease, and relatesthemanalyticallyto problemsof
human and culturalevolution.
EcologicallyOrientedStudiesof IsolatedGroups
Small groupslivingin relativeisolationoffera particularlygood op-
portunityto examinethe interplaybetween environment, culture,pop-
ulationchanges,and disease. Such groupsare believed to representthe
best existingapproximationto the typesof conditionsthat presumably
gave rise to human variabilityand allow focusingon theoreticalques-
tionsthatmay yield insightsregardinghuman evolution.Multidiscipli-
nary,systems-oriented studies dealing with isolated groups have been
numerousduringtheperiodunderreview.The concernsof the Interna-
tional Biological Programinclude an examinationof the influenceof
disease in the adaptation of isolated groups (see Baker and Weiner
1966). The generalcommentsofferedby Gajdusek (1964, 1970a), Neel
and Salzano (1964), and Neel (1970) dealing with the potential of
these studies fromthe standpointof medicine and populationbiology
shouldbe consulted.Medicallyorientedstudiesof small isolatedgroups
having "primitive"formsof social organizationare often conducted
withina frameworksimilarto that used to examinethe adaptationsof
variouspeoples to differenttypesof harsh environment(Baker 1966).
This frameworkhas been termed by Lasker (1969) the "ecological
approach" in physical anthropology.
The series of papers on the Xavante, Makiritare,and Yanomamo

MEDICAL ANTIROPOLOGY 197
Indians, three South American huntingand gatheringgroups (Neel
and Salzano 1967; Neel et al. 1967,1968a,b;Niswander1967; Weinstein
et al. 1967), containa great deal of information on factorsrelated to
disease. Informationderived fromphysical examinations,analysis of
peripheralblood specimens,dental examinations,and examinationof
sera, urine,and stool specimenshave been reportedin various publi-
cations.The Xavante are, in general,in an excellentstate of physical
health,and observationsindicate the same picturewith regard to the
Makiritareand Yanomamo.For reasonsthat are not entirelyclear, Xa-
vante women appear less healthy than men. There is an unresolved
paradox broughtabout by the apparent excellenthealth of the young
and the absence of elderlyindividualsin the group. Infantand child-
hood mortalityrates are high when comparedto highlycivilized coun-
tries,but low when comparedto underdevelopednationssuch as India
at the turnof the century.Serologicevidence suggeststhatthesegroups
have experiencedextensivecontactswith a varietyof potentiallydis-
ease-producing,infectiousagents.To a verylarge extent,then,the eco-
logical setting(i.e. disease agents therein) influencesdisease patterns.
Newborninfants,who appear to possess ratherhighmeasuresof mater-
nal antibodyacquired transplacentally, are fromvery early in life ex-
posed to a varietyof pathogens.The ratherlong period of lactationand
the excellentnutritionalstatusof the child allow fora relativelysmooth
transitionfrompassive to active immunity. A numberof additionalob-
servationsof the health statusof these subjects have been included in
several of the papers. The studiesconductedby Neel and his group,of
course,have a broad and diversifiedfocus,and in addition to dealing
with disease agents per se, they include such issues as cytogenetic
changes,the distributionof geneticmarkers,and considerationsof the
movementsand changesin populationgroups.A ratherhigh degree of
intratribalgeneticdifferentiation across Indian villages has been docu-
mented (Ward and Neel 1970). This findingis believed to reflectsto-
chastic events as well as more socially structuredfactorssuch as the
fission-fusion pattem of village propagation,the nonrandompatternof
intervillagemigration,and the geneticconsequences of the differential
fertilitythat is maintainedby polygyny.Among the Yanomamo,inter-
course taboos, prolongedlactation,abortion,and infanticidehave the
effectof reducingthe effectivelive-birthrate to about one child every
fourto fiveyears duringthe childbearingyears. This has led Neel to
propose that a formof prudentcontrolof the populationbase charac-
terizesthese Indian groups.
These studies,then,representexcellentexamplesof how interdiscipli-

naryresearchefforts thatinvolveanthropologists, biologists,and physi-

cians can be developed and coordinatedin the attemptto examine
problemsof disease and populationgenetics.Clarificationof theseprob-
lems may answerquestionsdealing withman's earlyhistory.In related
studies conducted by the same group,the response of the Yanomamo
Indians to a measles epidemic has been lucidly described (Neel et al.
1970). An implicationof thislatterobservationis thatsecondaryfactors
(such as the behaviorof the subjectsduringtheinfection-inparticular
theirapathy,the absence of fluidreplacement,and the general conse-
quences of an essential collapse of village life during the epidemic)
probably account formuch of the morbidityand mortalityassociated
with this disease. A serologicfollow-upon a small scale revealed that
"the ability of the Indian to formantibodies to an antigen to which
he may not previouslyhave been exposed appears no different from
-thatof the much exposed Caucasian" (p. 427). Thus, the long-held
view regardingan innate "susceptibility"to measles in the American
Indian is seriouslyquestioned by these data. (Additional data on the
health statusof theAmericanIndian can be obtainedby consultingthe
chaptersby Nutels,Burchet al.; Milleret al.; Giglioli,Riviereet al.; and
Barzelatto and Covarrubias in the publication of the Pan American
Health Organization(1968), Biomedical Challenges Presentedby the
Indian.)
American
The studiesof Gajdusek and his groupon kuru,the fatalprogressive
degenerativedisease of the centralnervoussystem,are also illustrative
of the directionthese studiescan take (see Alpers and Gajdusek 1965,
Zigas 1970,Alpers1970,and Gibbs and Gajdusek 1970). In thisinstance,
the studyof an unusual syndromein an isolated group (New Guinea
highlands) has led to brilliantexplorationsof the relationshipsbetween
culture,environment, and a specificdisease. What is more,biomedical
knowledge generatedby the studyof this disease (i.e. kuru) has had
an importantinfluencein stimulatingworkthathas led to the develop-
mentof refinedhypothesesabout the causes of a varietyof human dis-
eases. The disease kuru is confinedto membersof the Fore linguistic
group of New Guinea and those with whom theyintermarry. The dis-
ease, whichaccountedforthe mortality of over2 percentof the popula-
tioneach year,affectedmostlywomen and children,oftenproducinga
male-to-female ratio of 3: 1. Salient featuresof the distributionof this
disease have been explainedby means ofhypothesesthatinvokegenetic
and environmental factors.The disease is caused by a slow "latent"virus
forwhich thereis a genetic susceptibility.The thirdfactorin the ex-

MEDICAL ANTBROPOLOGY 199
pressionofthediseaseappearsto be thepracticeofcannibalism, which
isbelievedtoexposesusceptible individuals tocontaminated humanseg-
ments.Therehave been striking changesin thesex and age incidence
ofthedisease,and theseare believedto be due to socioenvironmental
changesin theregion,in particular the curtailment of thepracticeof
cannibalism amongthe Fore. Some of thesocialconsequencesof this
diseaseare describedby Gajdusek(1963). The modeofsearchforthe
etiologyofkurureflects clearlythemultileveled and holisticapproach
of humanecology.The studyof kuruhas stimulated the searchfor
similartypesof virusesin otherdegenerative diseasesof the central
nervoussystem(see Petrov1970;Mathai1970;and Yase 1970).
Someofthestriking biomedical characteristicsofpeoplelivinginsoci-
etiesofNew Guineahavealso been provocatively discussedby Gajdu-
sek(1970b). Theseincludeextremely slowgrowth patternsand delayed
puberty, whichtogether witha shortlifeexpectancy meansthatmany
New Guineanshave spentovertwo-thirds of theirlifeattaining full
sexualmaturity. The characteristic earlyagingofmanyNew Guineans
is notaccompaniedby thevascularchangesand highblood pressures
of agingin civilizedsocieties.Those showingextreme growthretarda-
tionareregularly foundtobe suffering frommalnutrition withlowtotal
proteinandcaloricintake, although theyfrequently do notshowclinical
manifestations ofmalnutrition.It is unclearto whatextentthepigmoid
build of someNew Guineansis determined by geneticfactorsas op-
posed to environmental ones.The landlockedNew Guineansin thein-
teriorvalleysliveina sodium-scarce environment. Comparedwith'civi-
lized"peoples,theseNew Guineansdemonstrate a reversalof the ex-
pectedvaluesof urinary sodiumand potassiumexcretion. Excessively
low saltand proteinintakelead to low urinary aminoacid and sodium
excretion, and to dailyurinaryoutputvalues thatare extraordinarily
reduced.Theirwirybuild withlittlesubcutaneous tissuesuggestsa
highdegreeofadaptation toheavyworkrequirements, withlow-weight
bodyframesthatare believedto be ideal fortheratherhighload-to-
bodyweightratios.Anunusualinsensitivity to painhas been observed.
Instancesofrelatively unusualbehavioralpractices(e.g. headhunting,
cannibalism, andmutilation)
scarification, havebeendescribed, though
thefullpsychological or behavioralimplications of thesepracticesre-
mainto be explored.
A seriesofstudiesconductedin thevillageofKenebain WestAfrica
illustrate
further thepotentialcontribution thatculturally and ecologi-
callyoriented studiesofmedicalissuescanmake(A. M. Thomsonet al.

1966a,b;B. Thompson1966,1967a,b;B. Thompsonand Rahman1967;

B. Thompson and Baird1967a-c;A. M. Thomsonetal. 1968;McGregor
et al. 1968,1970). One studyexaminedactivities and eventssurround-
ingthefirst twoweeksin thelivesofnewbornbabies.The activities of
pregnant women,culturalresponsestowardpregnancy, theprocessof
childbirth, and thecareand feedingofthenewbornwerepresented in
richdetail.It was shownthatimmediate wet-nursing and demandfeed-
ingfrombirthhad no obviousill effects on theneonates,a finding that
tendsto weakena prevailing view thatnewbornsshouldbe deprived
ofmilkduringtheirfirst daysoflifebecauseofpotential ill effects.
The
timeof the yearwhenbirthoccurredwas shownto have significant
consequencesin suchissuesas childcare,feeding,and evensurvival.
In anotherstudy,theweightchangesin pregnant and lactatingwomen
wereevaluatedas a function of timeand seasonof theyear.Changes
notedwererelatedto workand leisurecharacteristics, whichreflected
behavioralpatternsimposedby the cultureas well as availability of
food,thelattertiedto features oftheecosystem. The paperby Brazel-
tonetal. (1969) is another ofhowbiologically
illustration relevant data
abouthumandevelopment can be enrichedby beingrelatedanalyti-
callyto theculturalframework. Theseinvestigatorsreporttheirresults
ofobserving childbirth
routines and earlydevelopmental phasesofchil-
drenin Zinacantan.Characteristics of adult Zinacantecans' behavior
werefeltto be mirrored in theseearlydevelopmental sequences.
Data ofthetypeproducedinthesestudieshaveheretofore beenlack-
ing;medicalknowledge has simplylackeddetailsofhow sociocultural
factorsinterrelate withbiomedicaleventsand processes.Studiesof a
similarnaturehave been reportedby Marsden(1964), Potteret al.
(1965), and Cravioto(1968).
SocialEpidemiology
Epidemiology, defined,is the studyof the distribution
briefly and
determinants of diseasefrequency in humangroups.The systematic
searchforfactors bearingon diseasehas classicallyinvolvedanalyzing
a varietyoffeatures ofthephysicalenvironment ofman.The term"so-
cial epidemiology" maybe usedto qualifystudiesthatattempt torelate
socialand culturalfactorsto specificdiseasesfoundin a populationor
socialgroup.An immediate aimofthesestudiesis to demonstrate that
theprevalenceand/orincidenceofdiseaseand itsdistribution in space
or in a socialsystem bear a relationshipto suchfactorsas culturalex-
clusivity, socialclass,or anyothervariablethatmaybe
ethnicidentity,
linkedto socialprocesses.Anultimate aimofsuchstudiesis to uncover

leadsthatwillhelpclarify howthesetypesoffactors maycontribute to
thecausesofdisease.A criticalrequirement ofa socialepidemiological
studyis thatthe social and/orculturalvariablesthatare examined
(variablesthatin thelogicofthestudy'sdesignare termed"indepen-
dent") be preciselyidentified and hopefully measured,and thatthe
influence ofthesevariablesin theweb of causationof diseasebe ana-
lyticallyspecified.
The rationaleofsocialepidemiology was clearlyexplicated by Cassel
(1964). Tyrolerand Cassel (1964) used thisrationaleto examinethe
effect ofurbanizationoncoronary heartdiseasemortality inNorthCaro-
lina. Mortalityrateswerecomparedamongruraland urbanresidents
ofthecountiesacrossa four-point urbanization gradient.The prediction
thatruralwhitemaleswouldexhibit an increaseinmortality fromcoro-
naryheartdiseaseas theindexofurbanization ofthecountyincreased
was empirically supported by thedata ofthisstudy.Thisfinding is ex-
plainedin termsof the incongruity thatruralresidentsexperience in
theircultureand social situationas urbanization increases.For other
examplesofepidemiologically orientedstudiesthatfocuson theinflu-
enceofculturalfactors on diseasesofthecirculatory system,thereader
canconsultCruz-Coke etal. (1964); FulmerandRoberts(1963); Mann
et al. (1964); Symeet al. (1964); Bruhnet al. (1966); and Sievers
(1967). These authorsall relyon indicators of culturalfactors(e.g.
urbanization, migration, othertypesof sociocultural change,cultural
exclusivity)and examinehowthesefactors affectratesand distribution
of arteriosclerotic
and hypertensive heartdisease.Recentsocial epi-
demiological studiesfocusing on thesediseaseshave tendedto relyon
morerefinedindependent variables(e.g. incongruity in social status
and degreeof manifest hostility: Shekelleet al. 1969;Ibrahimet al.
1966). Forreviewsofstudiesofthistypethereadershouldsee Sprague
(1966); Antonovsky (1968); Lehman(1967); and the Milbankissue
editedby Symeand Reeder(1967). An excellentreviewdealingwith
hypertensive diseaseis theoneby Henryand Cassel (1969). Theysur-
veyedtherecentepidemiologic literatureand literaturerelatingto ani-
mal experiments thatbear on hypertensive disease.A largenumberof
studiesdealingwithhypertension thatexaminetheinfluence ofcultural
variablesare also reviewed.Theyfindevidenceto supportthe view
that"a dissonancebetweenthesocialmilieuin laterlifeand expecta-
tionsbased on earlyexperiences duringthe organism's developmental
stagesmaybe oneofthecritical factors" (p. 196) in thecauseofhyper-
tension.
Scotchand Geiger(1963) evaluatedthe usefulness of the Cornell

MedicalIndex(CMI) (a symptom questionnaire containing itemsthat

mayreflect varioustypesofsystemdisorders)as a generalmeasureof
thehealthof a socialgroupamonga Zulu population(and subgroups
therein).They reliedon mortality ratesand elevateddiastolicblood
pressurelevels as independent indicatorsof healthstatus(see also
Scotch1963b). CMI scoresbore an appreciabledegreeof correspon-
denceto mortality ratesandmorbidity indices.The CMI scoresofvari-
ous subgroups differentiated on thebasisofsocialcriteria(i.e. age,sex,
place ofresidence, beliefin witchcraft), revealedsignificant contrasts.
These findings wereexplainedas correlates (or perhapsoutcomes)of
thegreater stressesthatindividuals in thevariouscategories experience.
An impressive degreeofinteraction was notedbetweenage and belief
inwitchcraft,withyounger believersdemonstrating higherCMI scores.
The designemployed didnotallowdetermining ifillnessled to espousal
'of witchcraftbeliefs,ifbelieversare especiallyproneto medicalprob-
lems,or whether bothof theseissueswere"caused"by anotherfactor
orfactors.The actualfindings contribute significantlyto an understand-
ingofhypertensive disease,andmustbe seenas enhancing thevalidity
of the CMI. The authorsalso suggestthattheindexmaybe used to
develophypotheses concerning sociocultural processes:"in the hands
oftheanthropologist-physician team,theCMI [orsimilarindices]may
servenot onlyto givea crudehealthprofileof a populationbut also
topointtopuzzles,pointsofstress, orareasofapparently highriskthat
deservefurther exploration bothmedically andbythemethods ofsocial
science"(p. 311).
The rationalefollowedby Scotchand Geiger,ofcourse,is similarto
thatused infieldstudiesofuntreated mentaldisorder. In thesestudies,
symptom questionnaires (and otherquestionnaires focusingon social
and demographic variables)are administered to a probability sample
ofa population.Later,thesymptom scoresareclinically ratedorjudged
bypsychiatrists.The estimates ofillnessor disability obtainedare then
relatedto socialand culturalfactors(presumably measuredindepen-
dently)thatare hypothesized to have a potentialcausal influence on
psychiatric healthstatus.The studiesof A. H. Leightonet al. (1963)
and D. C. Leightonet al. (1963) are typicalpsychiatric epidemiologic
studiesthatfollowthisrationale.In thesestudiesparticular attention
was givento the effects of socialdisorganization. For a discussionof
theassumptions as wellas theframework ofsocialepidemiologic studies
of psychiatric disorder,the readershouldconsultLeighton(1969);
Leightonand Hughes(1961); Leightonand Murphy(1965); Savage

et al. (1965), and Dohrenwend (1966). (For a generalpictureof the
issues involved,the reader should also consult the criticalreview by
Mishlerand Scotch (1965) on epidemiologicalstudiesof schizophrenia.)
Psychiatricepidemiologists,as a reading of the precedingempirical
and analyticstudieswill disclose,have resolvedthe centralproblemof
clearlyidentifyinga case or instanceof disease in a mannerthatis most
problematic(see also Dohrenwendand Dohrenwend1969). The attempt
to then quantifyamount of disease in a bounded social group and to
relatethisamountto ("independent") socioculturaleventsor categories
must be evaluated rathercautiously.It needs to be emphasized,how-
ever,thatfieldstudiesattemptingto linkindependenteventswith"dis-
ease entities"of any sortencounterrelated problemsof disease defini-
tionand measurement, and thatpsychiatricepidemiologyforthisreason
is in no way unique.
Most social epidemiologicalstudies tend to slightthe processes and
dynamicsof social eventsand personbehaviors.The papers by Graves
(1966, 1967, 1970) employa framework relatedto thosejust described
in that what could be termed"maladaptive"behaviors (e.g. excessive
drinking,police arrests) presumed to follow or expresspsychological
stress are studied in a rigorousmanner. However, these papers by
Graves are notable fortheiremphasison processes and for the sensi-
tivitywithwhich theycapture the social circumstancesthat the actors
find themselvesin. Althoughthe contentof these papers cannot be
viewed as typically"medical,"they are mentionedhere because they
do representattemptsat analyzinghow social and culturalfactorsaffect
adjustment,and theyfocuson behavioralprocessesthatare the outcome
or expressionof stress.
Ahluwalia and Ponnampalam (1968) addressed themselvesto the
potentialeffects ofbetel nutchewingamongplantationworkersof south
Indian origin.They obtained relevantmedical historiesand personally
conductedexaminationsof the oral cavitiesof 168 workers.No evidence
to support the hypothesisthat betel chewing causes oral cancer was
obtained,but a definiteassociationbetweenchewingand variouslesions
of themouthwas noted.In theirreport,no clear pictureof the sampling
frameis presented,and thus the generalizabilityof theirfindingsmust
be regarded as tentative.The paper by Buck et al. (1968a) (also in-
cluded as a chapter in theirbook) reportson some of the physical
health correlatesof coca chewing,a widespread practice in parts of
South America,particularlythe Peruvian Andes. In this study coca
chewerswere matchedwithnonchewerson the variablesof age, ethnic

affiliation,and sex. Coca chewers showed a poorer nutritionalstatus,

more evidence indicatinghookwormanemia, and poorer personal hy-
giene,and theyrated higheron indices suggestingseriousillness.Buck
et al. attributedthese findingsto the influenceof cocaine in maintain-
ing a state of malnutrition.The assumptionhere is thatcocaine reduces
the sensationof hunger,therebyeliminatingor reducingappetite and,
ultimately,food intake.A long-rangeconsequence of this is malnutri-
tion, which reduces "natural"defenses against infection.However, a
varietyof other factorsdistinguishedtheir controland experimental
groups,and since some of the factorshave clear health implications,
the exact influenceof coca chewingmust remainuncertain.In a very
interesting study,Negreteand Murphy(1967) workingin Bolivia found
some evidence that coca chewers tended to demonstrateevidence of
psychologicaldeficit,althoughthe nature of the deficitand the exact
role of coca in the clinicalpicturecould not be determined.Sampling
problemsencounteredduringthe conductof thisparticularstudylimit
the extentto which resultscan be generalized. (For a discussion of
social factorsassociated with coca chewing see Goddard et al. 1969.)
These studies,then,address themselvesto a culturallysignificant prac-
tice and examineitsadverseconsequencesin physicaland psychological
terms.
A numberof investigators have attendedmoregenerallyto the medi-
cal problemsthat are foundin specificculturaland sociallydifferenti-
ated groups. Chowdhuryand Schiller (1968) and Chowdhuryet al.
(1968), for example,studied the prevalence of intestinalhelminthin
religiousgroupsin a ruralcommunity near Calcutta. The prevalenceof
ascariasis was significantlygreaterin Muslims,whereas hookwormin-
fectionswere moreprevalentamongHindus. The authorswere not able
to offera satisfactory explanationfor these differences.Using mainly
secondarysources,Worth (1963a,b) reviewed the health problemsof
contemporaryrural China and indicated some of the government's
efforts to combat theseproblems.Walker (1969) reviewedthe general
literaturebearingon the amountof coronaryheart disease among the
Bantu of SouthAfricaand Indians livingin India as well as othercoun-
tries.He concluded that the differences observed probablystem from
"racial" factors.Graham et al. (1970) reportedon the resultsof the
tri-stateleukemiaproject,which examinedthe associationbetween re-
ligionand ethnicity. Jews(especiallyRussianJews),Russians,and Poles
all demonstratedsignificantly elevated risks. Horowitz and Enterline
(1970) studied patternsof mortalityfromlung cancer among ethnic

MEDICAL ANTBHOPOLOGY 205
groupsin Montreal,and relatedthese to knowledgeabout the smoking
historiesof the groups. In a carefullyperformedinvestigation,Reed
et al. (1970) studied Chamorro subjects living in differentcultural
milieusand foundno evidence to supportthe hypothesisthatmigration
and Westernizationare associated with an increased prevalence of a
and Jelliffe
varietyof diseases. Jelliffe (1963) and Price and Lewthwaite
(1963) studied the prevalence of malaria in various parts of Uganda,
and reportedhigh figuresof plasmodiumin children.Terespolskyand
Yofe (1965) described the patternof hospital admissionsin a geo-
graphicallybounded communityof immigrantsin Jerusalem,giving
attentionto the countryof originof the residents.Feldman et al. (1969)
and Kamath et al. (1969) reportedon the resultsof followingthrough
time the health status of a group of familiesin semi-urbanareas of
Vellore,south India. They workedwith public health nurses,and had
physiciansavailable to performmedical evaluation.They notedthatthe
amountof illnessin the familiesvaried a great deal and did not relate
in a clear fashionto familyincome,familysize, or geographicalsection.
A seasonal patterncould be discernedin the incidence of skin infec-
tion and respiratoryand diarrhealillness.The studyof Ashley (1968)
representsan interesting attemptto equate geneticexclusivity("Welsh-
ness") withfrequencyof specificdiseases. Welshnesswas indicatedby
language and surname,and these indicatorswere associated with par-
ticularmedical problems.The authorsare of the opinionthat,insofar
as environmentand occupation are similarin the two groups studied
(Welsh and non-Welsh),theirresultstouchingon differences in disease
incidence can be ascribed to genetic differences.For other epidemio-
logically orientedstudies the reader may wish to consult Florey and
Cuadrado (1968), Adelstein(1963); Rabin et al. (1965); and S. B. Le-
vine et al. ( 1970).
Epidemiologicalstudiesdealing withthe prevalenceand distribution
of various infectiousand parasitic diseases in preliterategroups have
been numerousduringthe timeintervalunder consideration.However,
a great many of these studies do not employwhat could be termeda
culturalperspective,nor do theyfocus on behavioral concomitantsof
the diseases. The aim of the investigator appears to be to specifystrictly
clinical aspects of disease as well as the amount of disease presentin
the group; how the variousdiseases are relatedto behavioralpractices,
or how culturalpatternsaffecttheirexpression,definition, or manage-
mentin the group is not a salientconcern (e.g. Price et al. 1963; Reed
et al. 1967; and Mata et al. 1965). A numberof investigatorswho do

206 HORACIO FABREGA,J3R.
focus on behavioral aspects do so strictlyfromthe standpointof how

existingbehaviorsmay"mechanically"affectthe distribution and spread
of disease,but culturalconsiderations per se receivelittleattention.The
paper by Bruch et al. (1963), forexample,specifiesin some detail the
varioussourcesof infectionand the behavioralpracticesthataffectthe
prevalence and distributionof diarrhealdiseases in Guatemalan high-
land villages. The perspectiveof the actor or group membervis-'a-vis
these diseases is not in focus.Indeed, the whole dimensionof the con-
sequences of disease,whichincludesthe nativeperceptionsand coping
responsesofvillagers,is not considered.(The paper by Scrimshawet al.
1969 containsa bibliographyofthemanyarticlesproducedby thisstudy
program.) Kouranyand Vasquez (1969) conducted a similarstudyin
Panama, but dealt exclusivelywith the influenceof type of dwelling
on prevalenceof enteropathogenic bacteria.Ch'i and Blackwell (1968)
have traced the cause of an endemic peripheralgangrene disease in
Taiwan (termed blackfootdisease) to the consumptionof deep-well
water that containsappreciable amounts of arsenic. Generallyspeak-
ing,then,in these studiesvarioussocial and behavioralpracticesof the
group have the effectof bringingpersons in associationwith unique
featuresof the setting,and theresultsare certaindisease pictures.How-
ever, the influencesof such issues as values, beliefs,or general orien-
tationsto life on the outcomesor consequences of the disease are not
described.
Sociocultural
MatrixofDisease
This sectionreviewsmedical studiesthat in general examinethe in-
fluenceof socioculturalfactorsfromthe additionalstandpointof what
is done about disease, what the manifestationsof disease are, and the
social consequences of discretedisease typesin specificgroups.Thus,
in contrastto epidemiologicstudies that treatspecificdiseases largely
as dependentvariables,in the studiesto be revieweddiseases (or bio-
medical problemsin general) tend to be also treated as independent
variables. This thenleads to the examinationof socioculturalissues as
theyaffectoutcomesor effects(i.e. as dependentvariables).
An excellentexampleof the contribution of thisframework forview-
ing medical problemsis illustratedin a series of papers by Schofield.
Two initialpapers coauthoredwith Parkinson(1963a,b) describedbe-
liefsand practicesthathave a bearingon health statusamong peoples
of the Sepik districtof New Guinea. In manyways, the focus of these
studies is similarto those reviewed in the section on ethnomedicine.

The principaldifference, however,is the attentionpaid to nativeorien-
tationsand practicesthathave an importantinfluenceon specifictypes
of biomedicaland public healthproblems.The aim of these studies,in
fact,can be describedas an attemptto arriveat a comprehensiveview
of medicallyrelevantdispositionsand behaviors,since biomedical cate-
gories are articulatedwith referenceto the ethnomedicalperspective.
In anotherpaper Schofieldet al. (1963) reportedon theirstudies of
tinea imbricata,a skin disease that is commonin the lowland section
of New Guinea. A varietyof factorsthat bear on the etiology,onset,
and distributionof the disease are discussed. Personal habits (particu-
larlydegree of cleanliness,diet,and closenessto infectedpersons) and
livingconditionsare reportedto be factorsaffecting the riskof primary
infection.Althoughthe disease appears to have no medical effecton
the fertilityof marriedwomen,the social effectsof tinea imbricatado
reduce the crude fertilityrate of infectedwomen,since theyare judged
to be less desirablewives and tend to marrylater.The disease also con-
tributesto bachelorhoodin males, and appears to cause economicand
educationalhandicapsas well. In a laterpaper, Schofield(1970) reports
on his observationsin the Ethiopian highlandsand discusses some of
the distinctivesocial and psychologicalreactionsto the presence of
leprosy.To some extent,in these studies there is manifesta fusionof
the perspectivesof medicine,ecology,and culturalanthropology.
An interestinguse of the social science perspectivein medicine in-
volves examiningthe influencethat social and culturalfactorshave on
the orientationsand behaviorsof personsvis-'a-visa particulardisease
thatis categorizedin termsof Westernbiomedicalscience.Thus, Impe-
rato (1969) studiedorientations towardmeaslesin theRepublic ofMali.
His materialcame fromspecificcase investigations as well as question-
naireresponsesofmedical officers who had been instructedto interview
villagers.The varioustribalnames formeasles,thepresumedcause, and
the attitudesof familiestoward active cases were obtained. He shows
that a number of clinical featuresof measles are recognized by the
group as being criterialin this disease, and that various folkpractices
are used withreferenceto thesefeatures.The deleteriousconsequences
of the practice (rooted in culturallyspecificconceptionsabout illness)
ofwithholdingfoodduringthe activephase of the disease are reviewed.
Topley (1970), who worked in Hong Kong, also studied traditional
ideas and treatmentsof measles. Her informationderives fromdirect
interviewswith informants, and she includes in her account a more
detailed presentationof the historicalbackgroundand the currentcul-

turalorientationsin the area of medicine. Measles is treatednot only
as a Westerndisease type,but also as a termdesignatingspecificbe-
haviorsand orientationsof the group.The latterpart of Topley's paper
focuses on anotherspecificfolk illness that also affectschildren,and
includesa personalizedanalysisof the mechanismforfolkillnesslabel-
ing. The papers by Gussow (1964) and Gussow and Tracy (1968) also
focuson a Western-defined disease type-namely leprosy-but involve
an analysiswithinthe framework of medical "career"and social stigma.
Bronks and Blackburn (1968) in a somewhatrelated study reported
on the social and psychologicalproblemsexperiencedby personswith
hemophilia.Elder and Acheson (1970) reportedon a study dealing
withthe influencethatsocial class had on the responsesand behavioral
pattems of personssuffering fromosteoarthrosis. Imperatoand Traore
(1968) workingin the Republic of Mali discussedthe contentof beliefs
regardingthe cause and mode of treatmentof smallpox.The authors
point out that although ideas regarding"why" a disease occurs may
be groundedin traditionalsupernaturalnotions,theseideas may coexist
with Westernscientificviews of "how" the disease developed. Hoeppli
and Lucasse (1964) workingin West Africatraced the historyand dis-
tributionof native beliefs about the cause, symptoms,and treatment
of sleepingsickness,a usuallyfataltrypanosomaldisease. They showed
that a numberof featuresabout this disease that are regarded as cri-
terial in Western scientificmedical knowledge had been recognized
and acted upon by residentsof the area.
Gelfand(1966) is intenton showinghow a biologicallyconstrueddis-
ease entity(schistosomiasis)can be expressedor manifesteddifferently
in individualshavingdifferent culturaland physicalcharacteristics(i.e.
Europeans vs. Africans).The studyhas samplingproblems,and some
of the categoriesused as indicatorsof the disease are rathergeneraland
hence problematic.However,the logic and intentof thisstudyis inter-
esting and deserves discussion.Gelfand showed that Europeans, who
tended to demonstratea smalleramountof excretedeggs, also tended
to show greaterphysicaleffectsof the parasiticinfestations-inparticu-
lar, greaterreportsof tiredness.Africanstended more frequentlyto
reportabdominalcomplaints.The studyoccursin the contextof Honey
and Gelfand'sprevious (1962) experienceindicatingthat a numberof
urologicalfindingsassociatedwiththisdisease differin culturalgroups.
(Traditionalepidemiologicinvestigations demonstrating thata particu-
lar disease typemanifestsdifferent pathophysiologicprofilesin alterna-
tive culturalgroupsbear on thissame issue of disease comparability-

see Blackard et al. 1965.) Thus, studies of this type bring into sharp
focus the question of what constitutesa disease or, more specifically,
what frameworkshould be used to definea disease. Gelfand uses a
strictlybiologisticframework(i.e., his indicatorsof disease are egg
countsofparticularparasites);yeta behavioralor manifestational frame-
work (one that relies on symptomsand expresseddisabilitiesas indi-
cators) mighthave led himto conclude thatdifferent diseases are actu-
ally being compared.
frameworks
The fact that different may be used to definea medical
occurrence(e.g. an illnessas opposed to a disease) means thatany one
frameworkis arbitrary,and furthermore it suggests that many inter-
related factorsmustbe takeninto account in the studyof disease. The
problemsposed by the existingnosologyof disease are currently receiv-
ing a great deal of attention.There is no reason to expect currentdis-
ease "types"to have a preciseidentityin nature.Feinstein,forexample,
has discussedat lengththeperniciousconsequencesforclinicalepidemi-
ology of changing disease classificationalschemes and has presented
cogent argumentsin favorof the view that "diseases" need to be seen
as sets of clusteredbiological factsratherthan as unitaryphenomena
(see Feinstein1967,chaps. 1-7, 1968a,b). It need hardlybe emphasized
that a Westerndisease type (i.e. indicated by biologisticunits) is at
any one point in time likelyto be expressedin ways that are affected
by culture.Thus, its symptomsare likelyto vary,and the orderedrela-
tionsbetween the various biological indicatorsthatwe may use to de-
fineit may be affectedby diet,level of activity,and climatologicalde-
mands. Similarly,the course and developmentof any one disease (its
"naturalhistory")will be subject to culturalfactors.(For additional
points the reader should consult MacMahon and Pugh 1970, chap. 2;
Tyroler1968; Cassel 1967; and Fabrega 1971b.) The problemof pain,
of course, poses related conceptual and methodologicalissues (see
Zborosky1969; Wolffand Langley 1968), as does also any biologically
specifiedprocess that has social and behavioral accompanimentsand
consequences.Thus, Solien de Gonzales (1964) has reportedpersuasive
observationsleading her to question traditionalassumptionsabout lac-
tation.Similarly,Obeyesekere (1963) analyzes the relevance of socio-
culturalfactorsforexpressionof pregnancy"symptoms"in a Sinhalese
village.What is more,an attemptis made to analyze the functionalcon-
sequences and implicationsof what mustbe seen as a bioculturalcom-
plex. (See also Hanson 1970; Kupferer1965; and Newman 1966.)
By way of summaryit can be said thatthese studiesillustratenicely

the way in which biological processes (i.e. the disease schistosomiasis,

pain stimuli,lactation,pregnancy) can serve as a matrixor foundation
forthe elaborationof what can be viewed as culturalcategories.Iley
offercompellingevidence for the need to employ alternativeframe-
worksin order to understandfullythe phenomenaof disease and hu-
man adaptation,and to clarifythe centralset of premisesthat serve as
the bases of our definitions about biomedicalphenomena.
Studies that focuson the factorspromotingor hinderingthe utiliza-
tion of medical facilitiesin Westernor acculturativesettingsillustrate
anotherimportantproblemarea where socioculturallyorientedstudies
have special relevance.Four sets of factorsseem to be consistently in-
voked in attemptsto explain the processesunderlyingthe use (or dis-
use, or delay in use) of Westernmedical care resourcesand facilities:
(1) economic(e.g. the "demand"forcare,the capacityof the consumer
to pay forservices,the coverage offeredby different typesof medical
insurance); (2) sociostructural(e.g. distance constraints,transporta-
tion impediments, organization
inefficient of care type of
institutions,
professional practice arrangements); (3) sociodemographic (e.g. age,
sex, social class, ethnicidentification of consumers); and (4) psycho-
social (e.g. perceived health status,perceived need forcare, attitudes
toward physicians,salience and definitionof illness). Quite obviously,
factors3 and 4 bear ratherdirectlyon culturalconsiderationsand for
this reason are frequentlyexamined by social scientistsinterestedin
medical phenomena.It should be clear that,since behaviorsrelated to
use of medical facilitiesare generated and organized by orientations
that involve health,illness,and medical care, a numberof studies re-
viewed in the firstsectionof thischapterbear on this questionof utili-
zation (e.g. Maclean 1965a, 1966,Press 1969), as do studiesconducted
by Americansociologists(Mechanic 1962; Suchman1965a-c; 1967; Zola
1966). For an excellent(though now somewhatdated) review of the
literatureon the utilizationof medical facilities,the reader is urged to
read the paper by Rosenstock(1966). The papers by Kasl and Cobb
(1964, 1966a,b) also deal withthisgeneralproblem.An examinationof
the many interrelatedfactorsthat affectuse of medical facilitiespro-
vides,in a sense,a meetinggroundor boundarysettingforstudiesthat
incorporateepidemiologicaland ethnomedicalframeworks. This is the
case because the specificbiomedicallydefinedproblemsor processes
thatlead to the decisionto seek medical care (i.e. the potentialanalytic
unitsof an epidemiologicstudyconducted in a hospital or clinic) are

givenmeaningsand interpretations alongthe linesdelineatedby cul-
turalcategories(i.e. by "ethnomedical" conceptsand practices).More
specifically,
amongthefactorsleadingdiseasedpersonsto avoidusing
medicalfacilities(therebyaffecting a diseaserate) are thecontrasting
meaningsand actionimplications thatare givento manifestations of
thedisease.In thesamefashion, thewholerangeofproblems stemming
fromthedifficulty of treatingor managing"problem" patientsmayre-
quirea processualfocusin whichdetailsofhowmedicalproblemsare
defined and evaluatedbythepatients appearas important analytic
vari-
ables (see Von Meringand Earley1966and Fabregaet al 1969). It is
perhapsnotan exaggeration to say thatanthropologists have nowjust
begunto tap thearea ofstudyinvolving thefactorsand processesthat
impedeorinterfere withthetreatment ofpatientswithmanifest disease
(Nall and Speilberg1967).
MedicalEcologyand MedicalEpidemiology: Summary
Studiesreviewedin thissectionemploywhatcan be termeda bio-
logisticframework towarddisease.In sucha framework, definingchar-
acteristicsofdiseasereferto biologicallyconstruedprocesses(e.g. dia-
betesis a disorderof carbohydrate metabolism), indicators
of disease
areconstituted ofdataderivedfromexamination ofthebody'sstructure
and/orfunctioning, usuallybymeansofspecializedprocedures (micro-
scopic,biochemical, radiographic,etc.),and thecauseormechanism of
thediseaseis explainedby meansofknowledgederivedfromWestern
biologicalscience(e.g. genetics,physiology, nutrition,
microbiology).
Studiesemploying thisframework have severalimplicationsfortradi-
tionalanthropological concerns.Someexamplesare (1) whencultural
or ethnicfactorsare involvedin understanding the causes,character-
istics,or consequencesof the disease,(2) whenbiologicalor cultural
evolutionary questionsare entertained,(3) whenadaptationis studied
in relationto specificenvironmentalor sociocultural or
characteristics,
simply(4) whendescriptive featuresofgroupslivinginisolatedsettings
orunder"primitive" forms ofsocialorganizationare sought.
An underlying themeguidingthisreviewof theliterature has been
thatthemanydifferent and emphasesofanthropology
orientations find
a meetinggroundwhenillnessand diseaseenteras fociin a particular
inquiry;and conversely, whenillnessand diseaseare underexamina-
tion,themanytheoretical aimsand methodological facetsof anthro-
pologycan be showntohaverelevanceand standto offer an important

contribution toanthropology andmedicine. Thatthisis equallythecase

withotherdisciplines willbe illustratedby examining a traditionalcon-
cernofpopulationbiology.
A questionthathas been repeatedly raisedis how diseasesoperate
ormayhave operatedas selectiveagentsin thecourseof evolutionary
humanhistory, and,moreimportant, theinfluence ofculturalfactors in
thispopulation-environment exchange.Thereare at leasttwo general
strategiesor analyticprocedures thatmaybe used to arriveat answers
to questionssuchas these.In thefirst one,generalculturalpracticesor
institutions thatmaysignificantly bear on the development, propaga-
tion,or treatment ofspecificendemicdiseasesare analyzedin relation
topopulation trendsand distributions in particulargeographic settings.
In analysesofthistype,theinteraction betweenculturalgroupsand a
particulardiseaseor groupof diseasesis generallyapproachedat a
ratherhighlevelofabstraction, and consequently, theissueofwhether
members oftheculturerecognizeeitherthevalueofa particular medi-
cal practiceor specificfeaturesof the diseasethattheymaybe con-
trolling is leftout of focus.On the otherhand,one can analyzehow
representatives of particular "preliterate"culturesactuallyrespondto
medicalphenomena; thatis to say,how theydefineillness,how they
treatit,how theyorganizetheirsocialliveswhentheyjudgeit to be
in theirmidst,and,especially, thepotential biologicalconsequences for
the groupof thevariousactionsthatare takenin responseto native
categories ofmeaning(Vayda and Rappaport1968). The requirements
ofthislatteranalyticstrategy are quitedifferentfromthoseofthefor-
merone,sincetheemphasisis on specific groupsin space and timeand
thetaskordinarily necessitates thattheinvestigator be presentin order
tomakedirectobservations. Sincetheinvestigatorhopestodemonstrate
thatculturalresponses to diseasehavesignificant consequences forthe
group'ssurvival, it is naturally imperative thathe be able to systemati-
callycomparehis observations regarding nativeclassification
schemes
withknowledgeof theactualbiologyof disease.This,then,underlies
thecloselinkthatexistsbetweenmedicineand populationbiologyon
theone hand and therathertraditional concernsof anthropology for
rigorousethnography on the other.It also reemphasizes the interdis-
ciplinary natureof "medicalanthropology."

GLOSSARY
The following is a shortlistof medicaltermsthatcan be used to focusand

organizeefforts in thefield.It can be viewedas a minimalnumberof terms
thatrequirepreciseidentification and specification
cross-culturally.
Disease: Designatesalteredbodilystatesorprocessesthatdeviatefromnorms
as establishedby Westembiomedicalscience.This stateis presumedto
have temporalextension. This statemayor maynot coincidewithan ill-
ness state.
HealthBehavior:Concems,actions,and/orpracticesexhibited byindividuals
duringan illness-free statethatare motivated by a desireto promotecon-
tinuedhealthand/orwardoffillness.The formand contentof healthbe-
haviorsmustbe presumedto varyin termsoftheirdegreeofculturalorga-
nizationand specificity.
HealthStatus:Unlessotherwise specified,
thistermdesignates an individual's
stateofhealthjudgedaccordingtoWesternmedicalcriteria. The termcan
alsobe appliedwithreference tolayandnativemedicalcriteria. Clearly,an
individualmayfeelwelland be judgednormalbyhimself and othersofhis
group.However,he mayat the same pointin timebe judged to be dis-
eased accordingto Westerenbiomedicalnorms.
Illness:Designatesthatsomeoneis sick,but the criteriaare socialand psy-
chologicaland logicallyseparatefromthoseemployedby Westernmedi-
cine. It is assumedthateitherbehavioral,phenomenologic, or biological
(symptomatic) indicatorslead lay individualsto designatea stateofcom-
promisedhealth.It is assumedthatseveraltypesofillnesseswillbe found
to organizemedicalactivities in a sociocultural
unit.At thesametime,it is
assumedthatto an indeterminate extentsocioculturalunitsprovidemodels
forsuchillnesses.Quite often,the ethnographer mayuse the term"folk"
to qualifya particular illness.Usuallythisis done because it is believed
thatquiteunusualor specificfeaturesof theillnessidentify it witha par-
ticularculturalgroup.Strictly speaking,however,all illnessesare folkin
the sense thatnativecategoriesalwaysstructure the form,content,and
interpretation givento an illness.
IllnessBehavior:A generaltermdesignating the concerns,actions,and/or
practicesthatare exhibited by thoseindividuals who are defined(by oth-
ers and by themselves)as sick.The termdesignatesgeneralresponsesto
stressand copingbehaviorsas well as morespecificand sociallyorganized
behaviors(i.e. sick-role behavior,patient-role behavior).
IllnessCareers:The temporally patterned behaviorsand transactions thatfol-
low fromthedefinition thatsomeoneis ill. Thistermdesignatesa chainof
behavior,and includesillnessbehavior,medicaltreatment, convalescence,
etc.,endingwhentheillnessand medicalcare episodedrawto a "natural"
close.It is assumedthatillnesscareersare to an indeterminate extentcul-
turallypatterned andthattypesofsuchcareerscanbe discernedin a socio-
culturalsystem.
IllnessRecognition: The phase or processinvolvingeitherego alone or ego
and alter(s) thathas as its outcomethejudgmentthatego is sickor ill.

214 HORACIO FABREGA, PR.
Duringthisprocess,it is assumedthatthe variouscriteriathatindicatea

stateof illnessare evaluated.The criteriamaybe linkedto visibleevents
or changeshavinga bodilylocus (rashes,vomiting),to behavioralsets
(slowedactivity,diminished functional capacity,etc.), and/orto reported
experiential or phenomenologic states(pain, weakness,changesin states
ofbeing). Thisis a crucialdecisionin thehealth-illness-medical-care cycle
and shouldnotbe assumedto followan invariant patternacrosscultures.
Medical Care: A set of one or moremedicalservicesadministered to an in-
dividualduringa periodofrelatively continuous contactwithone or more
providers ofservice,inrelationto a par-ticularmedicalproblemorsituation.
Whatis judgedtorepresent a "medicalproblem"obviously dependson the
culturalgroup.A constellation of symptoms may be judged to represent
one or moredistinct medicalproblems,and thusat any one pointin time
a personcan becomeinvolvedin one or moreepisodesof care each of
whichcorresponds to a differentmedicaltradition(e.g. ethnomedical and
Westernbiomedical).In thisinstance,themanifestations couldbe said to
elicittwo or moredifferent typesof care. It wouldbe important to deter-
mineif the personand familyinvolvedin thesepluralistic medicaltrans-
actionslinkthemanifestations to one ormoreillnesses, i.e. whetherthein-
dividualsassociatea givenset of symptoms withtwo (or more) illness
types,each ofwhichrequiresa specffic typeof care.
MedicalCare System:The constellation ofbeliefs,knowledge, practices, per-
and resources
sonnel,facilities, thattogether structureand patterntheway
in whichpersonsof a sociocultural groupobtaincare and treatment for
illness.
MedicalPractitioner: A personwho is sociallydefinedas havingthe ability
and capacityto treatillness.The degreeof social differentiation existing
in the culturalgroupwill determine(1) the extentto whichpracticing
medicineis a full-timeoccupation,(2) whether reimbursement is expected,
(3) thedegreeofidentified symbolslinkedto thepositionofpractitioner,
and (4) theextentto whichmedicalcare is keptseparatefromotherin-
stitutionsof thegroup.
MedicalService:The servicesreceivedby a personthatare designedto pre-
vent,diagnose,or treatillness (or disease). Medical servicesare here
judgedto be administered singlyat-discretepointsin time.Theircoales-
cencein timeleads to thedesignation "medicalcare."
Patient-Role Behavior:Concerns,actions,and/orpracticesexhibited by per-
sonswho are ill whichfollowfrom(or are a responseto) specificrelations
witha medicalpractitioner. The assumption is made thatthereare more
orlessspecific behaviorsthatare expectedofindividuals oncetheyassume
the statusof clientor patientwithrespectto a medicalpractitioner, and
thatcultureorganizesand patterns thesebehaviors.
Sick-RoleBehavior:Concerns,actions,and/orpracticesexhibited by persons
who are ill whichconform to theexpectations of thosearoundtheperson
by virtueof his acquiredidentity"sick."This termthus designatesthe
moresociallyorganizedbehaviorsthatill personsdemonstrate in relations
withfamilyand friends. The formand contentof thisbehavioris assumed
to be culturallypatterned to an indeterminate degree.

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Stanford University Press

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PeterK. Manningand Elena Padilla read earlierversionsofthischapterand offered

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finea stateofillness.Attheotherextreme arestudiesthatviewmedical

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In Cebuano Sorcery(1967), Lieban analyzes the social and cultural

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study,in short,attemptsto reviewall facetsof illness,disease,and

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mentof the manymedical findingsreportedby these authors.In addi-

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This sectionis divided into six distinctsegments:medical beliefs,ill-

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held by residentsof Indian villages and stressesthe fact thatthese be-

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was describedas less stable and economicallydeveloped. A numberof

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does not presentactual clinical material or descriptionsof behaviors

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constrainedby his generalinability

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tive"psychotherapies (in press) is verycompleteand shouldbe con-

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Zinacantanand foundno differences whensymptomatic components

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"medicalanthropology" hasalwayshad withpsychiatry. Mostindicators

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eitheras a specific butratherabstractbiologistic category(not articu-

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measureof culturalspecificity at the same timethat it allows forsome

MEDICAL ECOLOGY AND EPIDEMIOLOGY

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citedwithregardto healthproblemsofhunter-gatherers, also deals with

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overcomehealth hazards (the potentiallosses of the "game") in order

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naryresearchefforts thatinvolveanthropologists, biologists,and physi-

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1966a,b;B. Thompson1966,1967a,b;B. Thompsonand Rahman1967;

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MedicalIndex(CMI) (a symptom questionnaire containing itemsthat

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affiliation,and sex. Coca chewers showed a poorer nutritionalstatus,

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focus on behavioral aspects do so strictlyfromthe standpointof how