Culture and Disease

Culture Specific Diseases

• There are some diseases that have very limited distributions around
the world due to the fact that they are caused by unique
combinations of environmental circumstances and cultural practices.
These are generally referred to as culture specific diseases or culture
bound syndromes. Some cause relatively minor health problems
while others are very serious and can even be fatal.

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• An example of a relatively harmless culture specific medical condition
was "rave rash" in England during the late 1990's. This afflicted young
women who went to "raves", or large-scale pop music dance parties
that went on all night long. Aggressive dance motions without
wearing a bra sometimes led to a painful rash on their nipples--hence
"rave rash." Another more recent culture bound syndrome is
"toasted skin syndrome". This is a result of excessive use of laptop
computers resting on the lap. The heat from these devices over time
can cause a mottled discoloration of the skin on the legs.

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• Kuru is a fatal culture specific disease of the brain and nervous system
that was found among the South Foré people of the eastern New Guinea
Highlands. Until recently, it was thought that kuru is caused by a virus
with a prolonged incubation period. Evidence now points to prions as
being the cause. The symptoms include palsy, contracted face muscles,
and the loss of motor control resulting in the inability to walk and
eventually even eat. Kuru victims become progressively emaciated. The
South Foré called this disease "trembling sickness" and "laughing
sickness." The latter description was due to the fact that the face
muscles of victims were constricted in a way that looked like a smile.
Death almost always occurs within 6-12 months of the onset of
symptoms.
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• Kuru was first recorded among the South Foré at the beginning of the 20th
century and it progressively became more common up through the 1950's. At its
peak, it mostly afflicted women in their 20's and 30's. This caused major social
problems. Normally, men had several wives and children were taken care by
women. Now, however, there were too few marriageable women, and men were
left with the child care duties. Men were resentful and confused by their
situation. Since the South Foré had a personalistic explanation for illness, they
logically assumed that Kuru was the work of witches who used contagious magic.
As a result, people became very careful at cleaning up their house sites to make
sure that witches could not obtain any of their hair, fingernail clippings, feces, or
personal belongings. Witch hunts were organized and former witches were
forced to confess and then join anti-witch cults. None of these steps slowed the
rate of increase in the number of Kuru victims.
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• In the early 1950's, a team of Australian doctors began working to discover what
caused kuru in hopes of finding a cure. Anthropologists traced cases of the
disease in family lines to see if it was hereditary. Other field workers collected
water, soil, plant, and animal specimens to test for environmental toxins. All of
these attempts failed to discover the cause. In the late 1950's, an American
pediatrician named Carleton Gajdusek came to Papua New Guinea to try to solve
the problem. Through the microscopic examination of tissue from people who
died of kuru, he discovered that the disease organism was carried in the blood and
was concentrated in brain tissue. The means of transmission was cannibalism.
The South Foré ate their dead relatives as part of their funerary practices. Women
butchered the corpses and were the main cannibals. They also gave this meat to
their children. Men generally thought that it was unmanly. They had pigs to eat,
while the diet of women and children was normally animal protein poor.
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• In the early 1960's, cannibalism was outlawed in Papua New Guinea.
Since then, the kuru rate has dropped off significantly but has not yet
disappeared because of the very long incubation period for this
disease. Between 1996 and 2004, 11 people were diagnosed with
kuru. Apparently, all of them were born before 1950 and had
contracted kuru before the end of cannibalism. This meant that the
incubation period was 34-41 years in these cases.

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Culture Specific Mental Disorders
• Apparently, mental illness is present in all societies. However, the frequencies
of different types of mental illness vary as do the social connotations. What is
defined as a mild form of mental illness in one culture may be defined as
normal behavior in another. For instance, people in western societies who
regularly carry on animated conversations with dead relatives or other
supernatural beings are generally considered mentally ill. The same behavior
is likely to be considered healthy and even enviable in a culture that has an
indigenous world-view. Such a person would be thought fortunate for having
direct communication with the supernatural world. Traditionally among many
Native American societies, dreams and the visionary world were, in a sense,
more real and certainly more important than the ordinary world of humans.
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• Among the Saora tribe of Orissa State in India, young men and women
sometimes exhibit abnormal behavior patterns that western trained
mental health specialists would likely define as a mental disorder.
They cry and laugh at inappropriate times, have memory loss, pass
out, and claim to experience the sensation of being repeatedly bitten
by ants when no ants are present. These individuals are usually
teenagers or young adults who are not attracted to the ordinary life of
a subsistence farmer. They are under considerable psychological
stress from social pressure placed on them by their relatives and
friends. The Saora explain the odd behavior of these people as being
due to the actions of supernatural beings who want to marry them.
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 The resolution to this situation is to carry out a marriage ceremony in
which the disturbed person is married to the spirit. Once this
marriage has occurred, the abnormal symptoms apparently end and
the young person becomes a shaman responsible for curing people.
In the eyes of the society, he or she changes status from a peculiar
teenager to a respected adult who has valuable skills as a result of
supernatural contacts. This Saora example suggests that some minor
mental illnesses could be better viewed as ways of dealing with
impossible social situations. In other words, they are coping
mechanisms.

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• What a culture defines as abnormal behavior is a consequence of what it
defines as a modal personality. People who exhibit abnormal behavior in
western societies are usually labeled as being eccentric, mentally ill, or
even dangerous and criminal. Which label is assigned may depend on the
subculture, gender, and socioeconomic level of the individual exhibiting
abnormal behavior. In North America, the public acts of poor mentally ill
males are sometimes seen as being criminal. This is especially true if they
are ethnic minorities or living on the streets. In contrast, similar abnormal
behavior by rich males is likely to be viewed as being only eccentric. In the
former Soviet Union, important people who publicly opposed government
policy were sometimes considered mentally ill and were placed in mental
institutions where they were kept sedated "for their own good."
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• The standards that define normal behavior for any culture are
determined by that culture itself. Normalcy is a nearly meaningless
concept cross-culturally. For instance, in the Yanomamö Indian
culture of South America, highly aggressive, violent men are
considered normal and such individuals are often respected
community leaders. In contrast, the same behavior among the
Pueblo Indians of the Southwestern United States was considered
abnormal and dangerous for society. People who exhibited these
traits were avoided and even ostracized.

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• Many psychological anthropologists believe that the most meaningful
criterion for defining mental illness is the degree of social conformity
by an individual. People who are so severely psychologically
disturbed and disoriented that they cannot normally participate in
their society are universally defined as being mentally ill. For
instance, individuals who have difficulty relating to other people
because of their intense hallucinations, paranoia, and psychotic
defenses will very likely be defined as mentally ill and potentially a
danger to others in all cultures.

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• While mental illness is found in most, if not all, societies, there are
unique culture influenced forms that these illnesses can take. They are
culture bound syndromes. An example is Windigo psychosis . This
condition was reported among the Northern Algonkian language group
of Indians (Chippewa , Ojibwa , and Cree ) living around the Great
Lakes of Canada and the United States. Windigo psychosis usually
developed in the winter when families were isolated by heavy snow for
months in their cabins and had inadequate food supplies. The initial
symptoms of this form of mental illness were usually poor appetite,
nausea, and vomiting. Subsequently, the individual would develop a
characteristic delusion of being transformed into a Windigo monster.
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 These supernatural beings eat human flesh. People who have Windigo
psychosis increasingly see others around them as being edible. At the
same time, they have an exaggerated fear of becoming cannibals. A
modern medical diagnosis of this condition might label it paranoia
because of the irrational perceptions of being persecuted. In this case, it
is the Windigo monsters who are the persecutors--they are trying to turn
people into Windigo monsters like themselves. In contemporary North
American culture, the perceived persecutors of paranoids are more likely
to be other people or, perhaps, extra terrestrial visitors. Victims of
Windigo psychosis experienced extreme anxiety and sometimes
attempted suicide to prevent themselves from becoming Windigo
monsters.
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• Another example of a culture bound mental syndrome is koro in China
and areas of Southeast Asia where Chinese culture has diffused
(especially Vietnam, Malaysia, and Singapore). Koro is an irrational
perception that one's prominent sexual body parts are withdrawing into
the body and subsequently being lost. In the case of men, the concern is
that their penis and testes are shrinking. For women, the focus is on the
perceived shrinking of the vulva and breasts. In both cases it is a fear of
the loss of masculinity or femininity followed by premature death. Koro
is traditionally believed to be caused by "unhealthy sex" (e.g.,
masturbation or sex with prostitutes). It also thought to be caused by
"tainted" foods. An example of the latter occurred in Singapore in 1967.

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 A newspaper reported that koro had resulted from eating pork that
had come from a pig that was given a vaccination against swine fever.
This sparked an epidemic of hundreds of cases of koro. More
recently, another epidemic occurred in coastal Vietnam when some
mothers were shocked to see that the penis and testes of their
children had shrunk after swimming. This created a widespread panic
among mothers in a number of coastal communities. In some cases,
the mothers tried to pull out the penis and testes with their hands
and even hooks in order to make them larger. This resulted in the
penis being torn off some of the boys.

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Diseases and Medical Knowledge
What is Disease?
You may think that the answer to this is straightforward: disease is what doctors define to be ill
health. But the concept of ‘disease’ is more complex and is fundamental to understanding health
services.
You could define ‘disease’ as the absence of health and health as the absence of disease. But
this is circular. Defining ‘disease’ involves two approaches, selfassessment and professional
assessment. Self-assessment inevitably involves a subjective assessment of how one feels about
one’s own health. Therefore, it is often referred to as ‘felt need’ and is an indication of a person’s
‘need for health’. Given that such an assessment is subjective, we will vary in our perceptions. At
one extreme there are stoics who will put up with more than others. In contrast, there are
people who are hypochondriacal and will complain about the slightest problem.
Also, lay people may not distinguish between symptoms of disease and symptoms that are
normal or physiological such as those associated with pregnancy or teething.

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 Professional or biomedical assessment is based on objective, scientific
and often statistically based definitions of illness. Biomedical
observation uses signs and test results to define disease. Professional
definitions also encompass whether or not a cost-effective treatment
exists. In other words, it is a definition of a person’s ‘need for health
care’. It is sometimes referred to as ‘normative need’. Despite the
sophisticated methods used, it can still be difficult for professionals to
say that disease is either present or absent as most measures are
continuous (such as a blood sugar level) rather than dichotomous
(whether a bone is fractured or not) variables.

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 Disease is the aggregate of those conditions which, judged by the
prevailing culture, are deemed painful or disabling, and which, at the
same time, deviate from either the statistical norm or from some
idealized status. Health, the opposite, is the state of well-being
conforming to the ideals of the prevailing culture, or to the statistical
norm. The ideal itself is derived in part from the statistical norm, and
in part from the abnormal which seems particularly desirable.

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What are diseases?
Having explored the concept of disease, you will now look at the
different ways of categorizing diseases. Why is this important?
Imagine you want to assess how the health care costs for patients
with coronary heart disease have changed during recent decades. You
might analyse medical records by looking at diagnoses. But which
diagnoses should you choose? Ischaemic heart disease, degenerative
heart disease, angina pectoris, myocardial infarction, coronary
sclerosis and coronary insufficiency are all terms you may find in the
records. Your results will depend on the definition you adopt.

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 Medical knowledge is based on categorizing states of ill health into
discrete diseases. Diseases are patterns of factors (symptoms, signs)
that occur in many people in more or less the same way. But where
do the particular categories that we use come from? One way of
understanding a complicated system such as disease categorization is
to study it when changes occur. Changes occur for five reasons:

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1. Real changes in occurrence – for example, newly emergent diseases
such as HIV/AIDS and new variant Creutzfeldt–Jacob disease. Diseases
may also disappear –for example, sweating sickness (English sweat),
which occurred in five epidemics between 1486 and 1551 and then
disappeared; endemic Tyrolean infantile cirrhosis, which lasted from
1900 to 1974; and encephalitis lethargica, which appeared in Europe
and North America between 1919 and 1926. (Of interest and
considerable concern is the fear that the latter may be reappearing in
the twenty-first century.)

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2. Changes in name – many different names were used for the same
disease before the name coronary heart disease had been created, as
mentioned above (Stehbens 1987). Glue ear (otitis media with
effusion) is another example: the name for the same condition has
changed more than 50 times since the nineteenth century (Black
1984).

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3. Changes from single to multiple categories – this is a common
phenomenon with the progress of medical knowledge. For example,
diabetes was first split into diabetes insipidus and diabetes mellitus
on the basis of the appearance and taste of the patient’s urine. The
latter was then divided into type I and type II on whether or not the
problem was the failure of the person to create insulin or the failure
of their body to respond to insulin. More recently, molecular biology
has contributed to further subcategorization of diabetes.

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4. Changes in recognition of abnormality – this includes a range of
conditions where medicine has changed its view. Examples include
ptosis in the nineteenth century (the erroneous belief that the large
bowel should not be free to move within the abdomen, leading to
surgeons attaching the bowel to the abdominal wall) and night
starvation in the 1930s (the belief that people suffered from low sugar
levels as they slept and should, therefore, have a sugary drink before
going to bed).

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5. Uncovering of previously rare conditions – due to the reduction or
elimination of other prevalent conditions.

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 The concept of disease is dependent on social and cultural factors.
Medical knowledge is based on categorizing states of ill health into
discrete diseases. Analysing why these categories change over time
provides insight into how medical knowledge is generated. Cultural
beliefs, values and norms influence medical thinking. Cultural factors
account for many of the differences observed in international
comparison of health services.

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Medical Paradigms
Paradigm
An example, hypothesis, model, or pattern; a widely accepted explana
tion for a group of biomedical or
other phenomena that become accepted as
data accumulate to corroborate aspects of the paradigm's explanation
or theory, as occurred in the 'central dogma' of molecular biology.

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 1. A human being's mental model of the world, which may or may not conform to th
at of others but is often stereotypical.
2. In the philosophy of science, a general conception of the nature
of scientific operation within which a particular scientific activity is
undertaken. Paradigms are, of their nature, persistent and hard to
change. Major advances in science-
such, for instance, as the realization of the concept of the quantum or the significan
ce of evolution in medicine-
involve painful paradigmic shifts which some people, notably the
older scientists, find hard to make.

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Paradigm term introduced in 1960 by the science-
historian Kuhn; a widely followed way of
approaching an area of research, deriving from a notable early
achievement in the field and carrying forward
both its experimental methodology and its theoretical outlook.

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Paradigm
• a model or pattern. The set of values or
concepts that represent an accepted way of doing things within an
organization or community.
• Paradigm shift
• an adjustment in thinking that comes about as
the result of new discoveries, inventions, or real-world experiences.

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Societal Forces and the Bureaucracy

Societal Forces
1. This may refer to political culture, social culture and economical development of a
given society. These forces may determine educational theories that one may use
to educate and train the workforce.
2. This may refer to political culture, social culture and economical development of a
given society. These forces may determine educational theories that one may use
to educate and train the workforce.
3. Political culture, social culture, and economical development of a given society.
These forces may determine educational theories that one may use to educate and
train the workforce.
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 Societal forces are often listed as:
• economical,
• technological,
• socio-cultural,
• political-legal and
• international forces

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A bureaucracy is "a body of non-elective government officials" and/or
"an administrative policy-making group".Historically, bureaucracy was
government administration managed by departments staffed with
non-elected officials. Today, bureaucracy is the administrative system
governing any large institution.

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 Since being coined, the word "bureaucracy" has developed negative
connotations. Bureaucracies have been criticized as being too
complex, inefficient, or too inflexible. The dehumanizing effects of
excessive bureaucracy became a major theme in the work of Franz
Kafka, and were central to his novels, The Castle and The Trial. The
elimination of unnecessary bureaucracy is a key concept in modern
managerial theory and has been an issue in some political campaigns.

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 Others have noted the necessity of bureaucracies in modern life. The
German sociologist Max Weber argued that bureaucracy constitutes
the most efficient and rational way in which one can organize human
activity, and that systematic processes and organized hierarchies were
necessary to maintain order, maximize efficiency and eliminate
favoritism. Weber also saw unfettered bureaucracy as a threat to
individual freedom, in which an increase in the bureaucratization of
human life can trap individuals in an impersonal "iron cage" of rule-
based, rational control.

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Quality Improvement
Carrying out interventions correctly according
to pre-established standards and procedures,
with an aim of satisfying the customers of the
health system and maximizing results without
generating health risks or unnecessary costs.
Conformance to specifications

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• The Oxford English Dictionary (1988) defined quality as “the degree or
grade of excellence”.

• Agency for health care research and quality defind quality as “"the
degree to which health care services for individuals and populations
increase the likelihood of desired health outcomes and are consistent
with current professional knowledge."

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• National Association of Quality Assurance Professionals described
quality as “the level of excellence produced and documented in the
process of patient care, based on the best knowledge available and
achievable at a particular facility.”

• the Community Health Accreditation Program defined quality as “the

degree to which consumers progress toward a desired outcome”

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Dimensions of Quality
• Technical competence
• Access to service
• Effectiveness
• Efficiency
• Amenities
• Interpersonal relations
• Continuity
• Safety

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Health Care Domain
 Effectiveness. Relates to providing care processes and achieving outcomes as
supported by scientific evidence.
 Efficiency. Relates to maximizing the quality of a comparable unit of health care
delivered or unit of health benefit achieved for a given unit of health care
resources used.
 Equity. Relates to providing health care of equal quality to those who may differ in
personal characteristics other than their clinical condition or preferences for care.
 Patient centeredness. Relates to meeting patients' needs and preferences and
providing education and support.
 Safety. Relates to actual or potential bodily harm.
 Timeliness. Relates to obtaining needed care while minimizing delays.

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Approaches of Quality
• Quality Control (QC)
• Total Quality Management (TQM)
• Quality Assurance (QA)
• Continuous Quality Improvement (CQI)

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Quality Control
• Quality control in health care organization refers to activities that
evaluate, monitor or regulate services rendered to consumers.

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Quality Control Process
It is an eight-step process for monitoring and evaluating performance. It must include the
following steps:

• Establish control criteria.

• Identify the information relevant to the criteria.
• Determine ways to collect the information.
• Collect and analyze the information.
• Compare collected information with the established criteria.
• Make a judgment about quality.
• Provide information and if necessary, take corrective action regarding finding to
appropriate source.
• Determine when there is a need for re-evaluation.
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TQM
• A way to continuously improve performance at every level of operation in
every functional area of on organization using all available human and
capital resources.

• Aim to reduce the waste and cost of poor quality.

• The main elements of TQM are three:

- the customer, whose needs are paramount to the determination of quality,
- the teamwork as a mean of achieving quality,
- the scientific approach to decision-making based on data collection and
analysis.
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Quality Assurance
All of the activities that make it possible to
define standards, to measure and improve
the performance of services and health
providers so that care is as effective as
possible

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• defined as “the process for objectively and systematically monitoring
and evaluating the quality and appropriateness of patient care, for
pursuing opportunities to improve patient care for resolving identified
problem”.

• The focus of quality assurance is the discovery and correction of

errors. These activities are carried out by, quality assurance personnel
or department personnel.

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Continuous Quality Improvement (CQI)
• CQI is a cyclical process.
• It involves identifying an area where there is an opportunity for
improvement then outline the sequence of activities that should
occur in order to solve that problem, and implementing them.
• Once the cycle is completed it has to be determined whether the
problem has been solved.
• If the problem continues, the cycle should be repeated.

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Continuous Quality Improvement Cycle
There are seven steps involved in implementing CQI cycle:
• Step 1 identify an area where opportunities for improvement exists.
• Step 2 define a problem within that area, and outline the sequence
of activities (the process) that should occur in that problem area.
• Step 3 establish the desired outcomes of the process and the
requirements needed to achieve them.

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• Step 4 select specific steps in the process, and for each step list the
factors that prevent the achievement of desired outcome.
• Step 5 collect and analyze data about the factors that are
preventing the achievement of the desired outcomes of the desired
steps.
• Step 6 take corrective action to improve the process.
• Step 7 monitor the results of the action taken

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Quality Improvement Project
Quality improvement project:
1. Identify an issue
2. Build a team to address it
3. Define the problem
4. Choose a target
5. Test the change
6. Reconsider or extend the improvement efforts

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