Culture and Health E-Book

Michael Winkelman

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1070

Veröffentlichungsjahr: 2008

Beschreibung

Culture and Health offers an overview of different areas of culture and health, building on foundations of medical anthropology and health behavior theory. It shows how to address the challenges of cross-cultural medicine through interdisciplinary cultural-ecological models and personal and institutional developmental approaches to cross-cultural adaptation and competency. The book addresses the perspectives of clinically applied anthropology, trans-cultural psychiatry and the medical ecology, critical medical anthropology and symbolic paradigms as frameworks for enhanced comprehension of health and the medical encounter. Includes cultural case studies, applied vignettes, and self-assessments.

Leseprobe

Table of Contents

Title Page

Copyright Page

Table of Figures

List of Tables

Table of Exhibits

PREFACE

MEDICAL ANTHROPOLOGY’S PERSPECTIVES

CHAPTER OVERVIEWS

SPECIAL FEATURES OF THE TEXT

Dedication

THE AUTHOR

Acknowledgements

CHAPTER 1 - APPLIED MEDICAL ANTHROPOLOGY AND HEALTH CARE

LEARNING OBJECTIVES

CULTURE AND HEALTH

CULTURE, ETHNOMEDICINES, AND BIOMEDICINE

CULTURAL COMPETENCE IN THE HEALTH PROFESSIONS

CONCEPTS OF HEALTH

SYSTEMS APPROACHES TO HEALTH

SUMMARY

CHAPTER SUMMARY

SELF-ASSESSMENT 1.2. MINORITY HEALTH CULTURE ASSESSMENT

SELF-ASSESSMENT 1.3. CULTURAL DYNAMICS OF HEALTH

SELF-ASSESSMENT 1.4. CROSS-CULTURAL DEVELOPMENT

ADDITIONAL RESOURCES

CHAPTER 2 - DISEASE, ILLNESS, SICKNESS, AND THE SICK ROLE

LEARNING OBJECTIVES

EXPERIENCE OF MALADIES

BIOMEDICAL ASSUMPTIONS ABOUT DISEASE

SOCIAL MODELS OF MALADIES AND DIAGNOSES

ILLNESS AND SICKNESS ACCOUNTS

THE SICK ROLE AND SICKNESS CAREER

AIDS AS DISEASE, SICKNESS, AND ILLNESS

HEALTH BELIEFS AND EXPLANATORY MODELS

CHAPTER SUMMARY

SELF-ASSESSMENT 2.1. DISEASE, ILLNESS, AND SICK-ROLE EXPERIENCES

ADDITIONAL RESOURCES

CHAPTER 3 - CULTURAL COMPETENCE IN HEALTH CARE

LEARNING OBJECTIVES

CROSS-CULTURAL ADAPTATIONS IN HEALTH CARE

CULTURAL COMPETENCE

ANTHROPOLOGICAL PERSPECTIVES ON CROSS-CULTURAL ADAPTATION

CONCEPTS OF CULTURE

INTERPERSONAL SKILLS FOR INTERCULTURAL RELATIONS

SPECIALTY CROSS-CULTURAL APPLICATIONS OF MEDICAL ANTHROPOLOGY

USING CULTURE TO CARE FOR PATIENTS AND PROVIDERS

CHAPTER SUMMARY

SELF-ASSESSMENT 3.1. CULTURAL COMPETENCE ASSESSMENT

SELF-ASSESSMENT 3.2. SPECIFIC CULTURAL COMPETENCY

SELF-ASSESSMENT 3.3. CULTURALLY RESPONSIVE CARE

SELF-ASSESSMENT 3.4. GROUP EXERCISE

ADDITIONAL RESOURCES

CHAPTER 4 - CULTURAL SYSTEMS MODELS

LEARNING OBJECTIVES

CULTURAL MODELS FOR HEALTH ASSESSMENT

CULTURAL SYSTEMS APPROACHES TO HEALTH

CULTURAL INFRASTRUCTURE, STRUCTURE, AND SUPERSTRUCTURE

INFRASTRUCTURE

FAMILY INFLUENCES ON HEALTH AND DEVELOPMENT

UNDERSTANDING WORLDVIEW AND SYMBOLIC RESOURCES

COMMUNITY HEALTH ASSESSMENT

RAPID ASSESSMENT, RESPONSE, AND EVALUATION (RARE)

CHAPTER SUMMARY

SELF-ASSESSMENTS

ADDITIONAL RESOURCES

CHAPTER 5 - ETHNOMEDICAL SYSTEMS AND HEALTH CARE SECTORS

LEARNING OBJECTIVES

POPULAR, FOLK, AND PROFESSIONAL HEALTH CARE SECTORS

POPULAR-SECTOR HEALTH RESOURCES

FOLK SECTORS AND ETHNOMEDICINES

PROFESSIONAL HEALERS

CHAPTER SUMMARY

SELF-ASSESSMENT 5.1. POPULAR BELIEFS AND PRACTICES

SELF-ASSESSMENT 5.2. INTERVIEW: FOREIGN HEALTH BELIEFS AND PRACTICES

SELF-ASSESSMENT 5.3. FOLK HEALERS AND UNORTHODOX MEDICINE

SELF-ASSESSMENT 5.4. EXPERIENCING BIOMEDICINE

ADDITIONAL RESOURCES

CHAPTER 6 - TRANSCULTURAL PSYCHIATRY AND INDIGENOUS PSYCHOLOGY

LEARNING OBJECTIVES

CULTURE AND PERSONALITY

CULTURAL CONCEPTS OF NORMALCY AND ABNORMALCY

PERSONALITY AND SELF IN INDIGENOUS PSYCHOLOGY

POSSESSION IN CLINICAL AND CROSS-CULTURAL PERSPECTIVES

BIOCULTURAL APPROACHES TO INDIGENOUS PSYCHOLOGY

ETHNOMEDICAL THEORIES OF ILLNESS

CROSS-CULTURAL ETHNOMEDICAL SYNDROMES

CHAPTER SUMMARY

SELF-ASSESSMENT 6.1. CULTURE AND PSYCHOLOGY

SELF-ASSESSMENT 6.2. CULTURE AND NORMALCY

SELF-ASSESSMENT 6.3. CAUSES OF MALADIES

ADDITIONAL RESOURCES

CHAPTER 7 - MEDICAL-ECOLOGICAL APPROACHES TO HEALTH

LEARNING OBJECTIVES

MEDICAL ECOLOGY AND DISEASE

EVOLUTIONARY ADAPTATIONS AND HEALTH

GENETIC, INDIVIDUAL, AND CULTURAL ADAPTATIONS TO THE ENVIRONMENT

EPIDEMIOLOGY OF DISEASE

RACIAL AND ETHNIC CATEGORIES AND HEALTH

TRIUNE BRAIN STRUCTURES AND FUNCTIONS

EVOLUTION OF THE SICKNESS-AND-HEALING RESPONSES

EMOTIONS IN BIOCULTURAL PERSPECTIVE

CHAPTER SUMMARY

SELF-ASSESSMENT 7.1. ECOLOGICAL ASSESSMENT OF DISEASE CAUSATION

ADDITIONAL RESOURCES

CHAPTER 8 - POLITICAL ECONOMY AND CRITICAL MEDICAL ANTHROPOLOGY

LEARNING OBJECTIVES

POLITICAL ECONOMY APPROACHES TO HEALTH

CRITICAL MEDICAL ANTHROPOLOGY

SOCIAL CONDITIONS AS CAUSES OF DISEASE AND HEALTH

SOCIAL NETWORKS AND SUPPORT

MACROLEVEL SOCIAL EFFECTS ON CLINICAL HEALTH

CHANGING HEALTH THROUGH PUBLIC POLICY AND COMMUNITY INVOLVEMENT

SELF-ASSESSMENT 8.1. POLITICAL-ECONOMIC EFFECTS ON HEALTH

ADDITIONAL RESOURCES

CHAPTER 9 - PSYCHOBIOLOGICAL DYNAMICS OF HEALTH

LEARNING OBJECTIVES

CULTURAL HEALING

RELIGION, RITUAL, AND SYMBOLIC HEALING

STRESS RESPONSE

PLACEBOS AND PLACEBO EFFECTS

PSYCHONEUROIMMUNOLOGY

METAPHORIC PROCESSES IN SYMBOLIC HEALING

CHAPTER SUMMARY

SELF-ASSESSMENT 8.1. PSYCHODYNAMICS OF STRESS AND WELL-BEING

ADDITIONAL RESOURCES

CHAPTER 10 - THE SHAMANIC PARADIGM OF ETHNOMEDICINE

LEARNING OBJECTIVES

WHAT IS SHAMANISM?

THE INTEGRATIVE MODE OF CONSCIOUSNESS

NEUROGNOSTIC STRUCTURES

BASES FOR SHAMANISTIC THERAPIES

SHAMANIC ROOTS IN CONTEMPORARY RELIGIOUS EXPERIENCES AND HEALING

CHAPTER SUMMARY

SELF-ASSESSMENT 10.1. SPIRITUAL EXPERIENCES AND HEALING

ADDITIONAL RESOURCES

GLOSSARY

REFERENCES

NAME INDEX

SUBJECT INDEX

Table of Figures

FIGURE 1.1. Biocultural Interactions: Hierarchy of Natural Systems

FIGURE 6.1. Expanded Psychocultural Model

FIGURE 8.1. Levels of Health Care Systems.

List of Tables

TABLE 2.1 Age-Adjusted Death Rates (per 10,000) for Selected Causes of Death in the United States, 2004

TABLE 4.1. Major Aspects of Cultural Systems

Table of Exhibits

EXHIBIT 1.1. Self-Assessment 1.4 Scoring: Cross-Cultural Development

EXHIBIT 3.1. Values Assessment Exercise

EXHIBIT 4.1. Conceptual Framework for Cultural System Health Assessments

EXHIBIT 4.2. RARE Phases, Principles, and Advantages*

EXHIBIT 4.3. RARE Assessment Modules*

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PREFACE

Cultural factors are central issues in the health problems that confront the world today. When reading newspapers and magazines, I find a barrage of information about cultural, social, economic, and political factors that impact the health of people around the world. Culture and health interactions are involved in cardiovascular deaths due to lifestyle; in soft-drink bans in public schools; in the epidemics spreading around the globe; and in deaths due to pesticides, infant diarrhea and dehydration, cigarette smoking, and the side effects of drugs such as Vioxx. Cultural factors are central to health issues of obesity, accidents, problems of the homeless and medically uninsured, child sexual abuse, and drug addiction. Social, economic, and cultural factors underlie major international health problems, including the spread of the acquired immunodeficiency syndrome (AIDS) epidemic, infant mortality due to preventable disease, the prohibitive cost of pharmaceuticals, diseases from environmental contamination, and social pathologies such as mental illness and violent assault.

In examining these health problems, I see that these are not simply medical problems with established clinical or pharmacological solutions but societal problems with complex cultural dimensions. These health conditions are generally not directly caused by biology—genetics, viruses, or bacteria—but, rather, by the effects of individual and collective cultural behaviors such as diet and resource allocation. How can we as a society come to understand and manage the social and cultural conditions that affect health?

I wrote this text on culture and health to present basic anthropological perspectives for understanding disease and illness and promoting healing and health. The text has two main audiences: health science students, particularly those in medical anthropology, nursing, and public health, and health care professionals, including physicians, nurses, psychologists and counselors, and public health and social workers. Both students and professionals need to understand how cultural perspectives can enhance the management of disease, assist in the promotion of health behavior, and provide a basis for culturally responsive care. This requires an understanding of the perspectives of medical anthropology.

MEDICAL ANTHROPOLOGY’S PERSPECTIVES

Medical anthropology’s biocultural approach expands the biomedical perspective that views health as basically a biological issue. Human health and disease derive from the interaction of humans’ biological potentials with numerous environments through culturally, socially, and individually mediated experiences that have effects on biological processes. Understanding how culture affects health enhances providers’ understanding of health problems and the needed care. The cultural and social effects on health and health care also mean that “we the patients” need to understand these effects, empowering consumers to manage health care interactions with greater awareness of the cultural, social, and institutional factors affecting health and treatment access. Cultural models provide frameworks for consideration of the impacts on health through culturally mediated interactions of human biology with the environment.

Cultural Competence and Responsiveness

This text provides perspectives and knowledge of medical anthropology that help health professionals provide culturally sensitive, responsive, and competent health care. I share perspectives acquired across two decades of teaching nursing, public health, and anthropology students, and learning from them as well, about the roles of culture in provider-client interactions. Education about cultural patterning of health and health care is a fundamental aspect of the preparation of health care professionals. It is also part of the broader roles of medical anthropologists as cultural brokers mediating between cultures, professional groups, institutions, and conceptual frameworks. Anthropologists’ roles as intermediaries in relationship to biomedicine, the dominant paradigm of Western medicine, includes (1) explaining the cultural dimensions of biomedicine and other healing processes to providers and patients, (2) explaining healing processes that lie outside the current understandings of biomedicine, and (3) providing education to facilitate mediation across these different conceptions of health and care.

Cultural Systems Models

Many factors affect health: personal behaviors; nutrition; environmental conditions; exposure to infectious or noxious agents; and availability of health care resources, social support, and material assistance. The ability to avoid and resist diseases derives from effects of many cultural beliefs and practices on health behaviors and physiological responses. Cultural systems models provide tools for organizing our understanding of the many factors that have effects on health. This integrative cultural perspective is reflected in models developed in medical anthropology, biomedicine, nursing, and public health to address cultural effects on health conditions, behaviors, and outcomes. These models show how diverse aspects of environment, society, and culture shape health and responses to disease. These interactions are illustrated throughout the book in essays that examine the factors relevant to the elevated levels of cardiovascular disease among African Americans.

Cultural Effects on Biology

Medical anthropology addresses the interrelations between biology and culture to show how culture has effects on health and disease. Cultural factors engage symbols with biology in a mind-body dynamics manifested in traditional healing practices, psychosomatic illness, “spontaneous remission of diseases,” and other ways in which beliefs affect our health. Perspectives of “psychophysiological symbolism” address how cultural meanings—symbols—have effects on human physiology. Consequently, traditional cultural beliefs regarding causes of illness—spirit aggression, witchcraft, and possession—have effects on psychophysiological processes, including inducing both healing and stress responses. Cultural rituals evoke physiological, emotional, and psychological healing processes and engage social support and elicit group bonding that provokes the release of neurotransmitters. These kinds of cultural effects on biological processes underlie the efficacy of traditional healing practices as well as the high incidence of some diseases, such as cardiovascular disease among African Americans.

Ethnomedicine and Alternative Medicine

My studies of ethnomedicine, the healing traditions found in every culture, have shown me that ritual healing practices have effects at physiological, psychological, emotional, symbolic, and social levels, providing many healing mechanisms. Ethnomedical practices can make important contributions to future health care, just as herbs contributed to the development of the biomedical pharmacopoeia. An “anthropological medicine” derived from cross-cultural health practices, exhibited in the alternative and complementary medicine used by people around the world, contributes new possibilities for physicians by expanding perspectives on health resources. Readers of this book have undoubtedly seen, and probably used, one or more of the many alternative medicine treatments available today: herbal teas, special diets, healing crystals, acupuncture, hypnosis, and spiritual and energy healers. So-called alternative and complementary treatments are a health treatment industry serving more than a hundred million Americans and producing an economy valued at billions of dollars annually in the United States. Medical anthropology helps us understand why these treatments are so popular and their roles in relationship to biomedical care.

Understanding Health Activities as Cultural Practices

Medical anthropology can help you, whether practitioner or consumer, become more aware of the cultural dimensions of health and disease and how they are affected by behaviors, beliefs, societal institutions, and the social relations involved in treatment. Health care always involves many aspects of culture, and health institutions function as cultural systems influenced by values, beliefs, and other biases. This text helps demystify biomedicine and its cultural aspects. Awareness of the social, economic, and political dimensions of health make both providers and consumers better prepared to address health needs and options effectively.

CHAPTER OVERVIEWS

The chapters address major cultural perspectives in understanding health and facilitating health care. The first five chapters introduce perspectives of medical anthropology and cultural systems analysis that illustrate a wide range of health concerns in which cultural factors have important roles. These chapters introduce approaches for the development of cultural competence that are applicable across the helping professions. They illustrate the roles of medical anthropology and cultural knowledge in enhancing the quality of services provided by professionals and in empowering clients to better understand the cultural context of their health and care. This requires an understanding of the systemic nature of cultural and environmental interactions through cultural systems models. These models detail the range of factors in the physical and social environments and the cultural behaviors, beliefs, and practices that affect health. Self-assessments at the end of each chapter direct readers to examine these relationships in their personal life, other cultures, and society. Chapters Six through Ten examine anthropological approaches that illustrate mechanisms through which cultural, ecological, political, and mental processes affect physiological responses and health. Each chapter addresses one of the major anthropological paradigms for studying health: transcultural psychiatry, medical ecology, political economy, and symbolic and shamanic perspectives.

Chapter One illustrates the importance of cultural perspectives in health care by showing that health involves broader cultural and personal concerns than addressed by Western medicine. Contemporary community health approaches require an understanding of the diverse cultural groups in society to develop appropriate public health programs. Cultural diversity requires that health care providers ascertain patients’ perspectives and develop the cultural competence to address their care needs effectively. The relationship of health to biological and cultural influences illustrates the necessity of a “biopsychosocial” perspective. Cultural systems models are introduced as frameworks for the analysis of health problems and the diverse impacts of culture on health. These perspectives illustrate how both the physical and cultural environment and other forces in society affect health and disease. This provides a range of areas of application for medical anthropology. Readers’ levels of cross-cultural competence are assessed in Self-Assessment 1.4.

Chapter Two addresses the fundamental importance of cultural issues in different concepts of health maladies—disease, illness, sickness, and the sick role—and the relationships of cultural and biological processes in producing them. Cultural influences on disease illustrate the limitations in the biomedical model and the socially constructed nature of health maladies. Culture is shown to influence biomedical conceptualizations of health maladies and treatments. Similar social and cultural effects shape the personal experience of illness and the social response to the diseases that produce sickness: socially induced suffering. This chapter introduces the health belief and explanatory models as tools for assessing culture and health relationships and determining the health and disease beliefs that guide patients’ health behaviors and responses to health care providers. Self-Assessment 2.1 provides direction for examining the personal and cultural bases of one’s own and others’ health beliefs and behaviors, providing the self-awareness necessary for adapting to cultural effects on health practices.

Chapter Three focuses on the general dynamics of cross-cultural adaptation and the development of cultural competency, applying its principles and skills for improving client-provider relations and enhancing the well-being of health practitioners. Cultural competence is achieved through employing anthropological perspectives and developing personal, interpersonal, and professional skills. These perspectives emphasize the recognition of, respect for, and accommodation to patients’ beliefs and preferences and the development of appropriate communication skills, social relationships, and negotiation approaches to engage patients in their treatment. These roles of cultural perspectives and anthropology in clinical practice and public health are illustrated in mediation, advocacy, education, program development, research, administration, and consultation functions of applied anthropologists. Clinically applied anthropology provides approaches for overcoming cultural problems in doctor-patient relations and enhancing care through cultural competence. The importance of culture in clinical assessment and care is illustrated, as is the role of culture in improving the care of both patients and providers. Medical anthropology also addresses the needs of biomedical practitioners by providing cultural knowledge that facilitates effective clinical practice in reducing cultural conflict and misunderstandings.

Chapter Four illustrates diverse areas of cultures’ effects on health through applying cultural systems perspectives. Examples are provided in the areas of diet, reproduction, pregnancy, and family organization. Health care providers and consumers can acquire broader perspectives on the nature of care by being aware of the therapeutic approaches of other cultures’ ethnomedical practices and cross-cultural patterns of health practices. This “witch doctor’s legacy” and anthropological medicine provide guidelines for the modifications of physicians’ styles to enhance patient and community relationships. A significant feature of cultural approaches is their ability to provide healing as opposed to a cure. Community involvement in health can be achieved through ethnographic approaches. Guidelines are provided for implementing policy approaches and programs sensitive to community needs through assuring their involvement and empowerment. The anthropological rapid ethnographic assessment, response, and evaluation models are ideals for incorporating communities into health care assessment, planning, development, and delivery.

Chapter Five examines the major sectors of health care resources: the popular, folk, and professional sectors. Popular culture’s health beliefs and practices have important implications for biomedicine; they are the context for decision making and the first line of resources for the care of health problems that often replace biomedical care. Popular culture involves social and personal factors that affect the recognition of symptoms, expression of pain, care-seeking behaviors, and access to health resources. Folk medicine and other alternative medicines are also frequently used in conjunction with biomedical care, potentially causing treatment complications. I review principal aspects of the complementary and alternative ethnomedical traditions found in the United States. Cultural factors also affect the professional sector of biomedicine, particularly the interpersonal dynamics of clinical relations. Recognition of these cross-cultural dynamics can make providers more effective in patient care and patients more effective in managing their clinical visits.

Chapter Six introduces psychiatric anthropology and transcultural psychiatry. These areas are concerned with the nature of humans and the manifestations of physical and psychological maladies in cross-cultural perspectives. Cultural programming of concepts of self and psychology provides the basis for cultural definitions of conditions of normalcy and abnormality and deciding whether behavior constitutes psychopathology or a normal cultural response. These perspectives are illustrated in the assessment of cultural factors that can be confused as psychopathologies. The concept of indigenous psychologies is presented as a cultural framework for understanding the nature of self and others. These cultural adaptations to biological universals, such as gender conceptions of male-female differences, are examined within the context of psychocultural models. Psychocultural models provide a framework for describing cultural psychologies and their environmental, social, and cultural effects on universal human potentials. These psychocultural systems perspectives provide characterizations of ethnicity in the cultural shaping of personal and social identity. The cultural shaping of self is illustrated in the phenomenon of “possession,” where spirits are thought to take over the personality of an individual. These conditions and other culture-bound syndromes (folk illnesses) are analyzed according to their relationships to biomedical classifications, cultural conceptions, psychosocial dynamics, and the manifestation of specific biological responses. Cross-cultural perspectives identify both universals of ethnomedical theories derived from human nature and culturally specific illnesses derived from particular cultural dynamics and social conditions. The relation of these ethnomedical conceptions to biologically based response patterns illustrates culturally specific adaptations to and shaping of innate physiological responses.

Chapter Seven presents the medical anthropological perspectives of medical ecology and biocultural perspectives on evolutionary adaptations affecting health. These interactions are illustrated in evolutionary medicine, nutrition, reproduction, emotions, and the evolution of human healing responses in the capacities for caring and empathy. Interactions of biological potentials and cultural influences include individual and group adjustments (acclimatization) and evolutionary adaptations that produce both susceptibility to and resistance to disease. Classic epidemiological perspectives on morbidity and mortality are presented, illustrated with U.S. ethnic differences in rates of death from specific causes of disease. These ethnicity and disease relations are explained with a cultural-epidemiological approach that assesses the causal and contributory sociocultural and behavioral factors in disease exposure and susceptibility. Consideration of the concept of “race” is used to illustrate human similarities and differences and the limitations of biological explanations in understanding human differences, including susceptibility to disease. An evolutionary basis for culture and health interactions is provided by the model of the triune brain and its different components, which provide a basis for understanding the symbolic cultural effects on emotions and stress responses. The relations among these major functional units of the brain provide a framework for understanding the factors shaping the evolution of human sickness and healing responses. These biocultural interactions are also illustrated in cross-cultural differences in emotions and the cultural shaping of emotional responses.

Chapter Eight describes critical medical anthropological approaches to health, introducing political-economic perspectives that illustrate how political and economic forces produce disease and differentially distribute risk and health resources. The impact of social class and economic factors on clinical interactions and patient care is illustrated in physician-patient behavior and the effects of poverty on the sick role. I show the importance of community building for health assurance by the evidence that social networks and support are significant mechanisms through which social relations have effects on health. Advocacy, policy development, and community empowerment approaches are tools through which anthropologists address societal discrepancies in health and work to ensure collective health and well-being.

Chapter Nine describes models of healing based in the interactions between symbols and physiological responses that provide mechanisms for ritual, religion, and belief to affect biological responses. The universal role of religion in cultural healing practices derives from its power to affect belief, motivation, and symbolic and social processes through which culture elicits endogenous biological mechanisms involved in adaptations to stress, anxiety, fear, and other emotions. Mechanisms of cultural healing involve symbolic manipulations of bodily responses through the associations established during socialization processes. Ritual activation of the autonomic nervous system provides bases for the mechanisms of placebo effects, hex death, and symbolic healing rituals. Understanding the relationship of the neurophysiology of stress to psychological and cultural processes provides a basis for understanding ritual effects on health through its symbolic effects on stress, anxiety, and fear. The placebo phenomena are examined as meaning-based symbolic cultural processes that have effects on physiological activity, providing an expanded view of disease and healing processes. These symbolic and social effects are further illustrated in the use of metaphors and myths to manipulate healing responses.

Chapter Ten introduces the most primordial of all ethnomedical practices, those associated with the shaman and shamanistic healing using altered states of consciousness (ASCs). Cross-cultural studies illustrate the commonalities and variation in shamanistic healers, magicoreligious practitioners who use ASCs in therapeutic activities. These universals of shamanistic healing involve neurological structures that provide the basis for therapeutic processes. ASCs represent universal psychobiological features of healing derived from an enhanced integration of brain functions. Variation found cross-culturally in shamanistic healing practices is related to social influences on physiological conditions. I review the psychobiological bases of ASCs, their psychophysiological effects, and the clinical evidence for their therapeutic efficacy. Therapeutic aspects of ASCs are examined in terms of their general physiological effects and through clinical and laboratory studies on specific procedures (e.g., drumming, meditation, music, and hallucinogens). Shamanic ritual mechanisms produce a range of psychosocial, cognitive-emotional, and psychophysiological transformations. The persistence of shamanic dynamics in contemporary illness and healing is illustrated. Shamanistic perspectives can contribute to modern medicine as therapies operating through socioemotional and psychophysiological mechanisms.

SPECIAL FEATURES OF THE TEXT

Medical anthropology’s integration of cultural and biological perspectives helps us better understand health problems and their solutions. The relevance of medical anthropology and cultural perspectives to biomedicine, and the interactions of culture and health, is illustrated in special features organized around Biocultural Interactions, Applications, Practitioner Profiles, Self-Assessments, Culture and Health, and Case Studies.

• Biocultural Interactions illustrate the effects of culture on biological processes, exemplifying a central point of this book: culture has direct effects on physiology.

• Applications present examples of how anthropology’s tools and perspectives can assist health professionals in understanding and resolving health problems.

• Practitioner Profiles are biographical sketches of some leading medical anthropologists and illustrate how they use cultural perspectives to address health problems.

• Self-Assessments have been provided at the end of each chapter to engage readers in the material discussed through a process of self-examination designed to help understand how cultural, social, and ecological factors affect health.

• Culture and Health essays present examples of cultural concepts in health, health care, and the expressions of illness.

• Case Studies, a classic teaching approach of biomedicine, are presented to illustrate the relevance of cultural information for health care by showing how it affects health behaviors and health care utilization and how anthropological approaches and cultural knowledge can assist in resolving health problems. Throughout the book, I have used examples of American ethnic groups to illustrate these cultural and health relations.

• Glossary items bolded in the text and compiled with definitions at the end of the book are provided to facilitate learning of specialized concepts from medical anthropology.

Case Study: A Clash of Spirits and Biomedicine

Throughout the book, a case study on a Hmong family is included to illustrate the cultural conflicts this ethnic group has experienced with biomedicine. I selected the Hmong because they became widely known to health care providers through Anne Fadiman’s (1997) award-winning book, The Spirit Catches You and You Fall Down. This “classic of medical anthropology” written by a journalist presents a tragic account of encounters between a Hmong family and their daughter’s physician and dramatically illustrates why medicine needs cultural and anthropological understandings. Fadiman’s account reveals how cultural conflicts and misunderstandings produced disastrous consequences: a brain-dead child in a permanent vegetative state.

Fadiman analyzes conflicts between staff in the Merced County Hospital and their Hmong patients through the tragedy that befell Lia Lee, daughter of mother Foua Lee and father Nao Kao Lee. The Hmong, who constituted a secret CIA army in wars in Southeast Asia, fled for their lives following the collapse of U.S.-supported South Vietnam. A people perpetually without a country of their own, many Hmong were relocated to rural California and other parts of the United States.

The Lees went to the hospital because of their infant daughter’s seizures but always arrived after the seizures had ended. Because of the lack of any translators, Lia Lee’s condition and its complications went undiagnosed for five months, leading to consequences that could have been avoided with an earlier diagnosis.

Conflict between biomedicine and Hmong culture regarding Lia Lee’s treatment led to her being removed from her family by court orders obtained by her physician. Although eventually returned to her parents, she suffered a major seizure that left her brain-dead at age three. One cause of her demise was an infection acquired in the course of her hospital treatments. Fadiman concludes that Lia’s life was ruined by cross-cultural misunderstandings that could have been prevented by anthropological approaches.

These case studies illustrate some crucial cultural issues that impede effective health care and that medical anthropological perspectives can resolve. The problems raised by Fadiman can be addressed by providing culturally responsive care for the Hmong, as described in Healing by Heart: Clinical and Ethical Case Stories of Hmong Families and Western Providers by Kathleen Culhane-Pera and coauthors (2003). The arrival of thousands of additional Hmong in 2004 illustrates the continued importance of understanding and effectively addressing the role of culture in health.

Audiences

This book addresses the roles of anthropology in developing cultural competency and cultural perspectives in health sciences and medicine. The intended audiences are students in the health sciences, particularly medical anthropology, medical sociology, nursing, counseling, social work, medicine, and public health, and the same fields of health professionals. My more than twenty years of providing cross-cultural training and teaching in medical anthropology and medical, nursing, and public health programs have shown me that the fundamental perspectives regarding cultural competency are relevant to all the health professions and medical social sciences. This book can be useful to diverse students and professionals because the underlying issues of culture and health interactions are the same for everyone: providers, support staff, and students, whether in nursing, anthropology, public health, psychology, or biomedicine.

How This Book Should Be Used

The dual audiences of the book—medical anthropology and health sciences—may suggest different strategies in using the text material. Students or practitioners of nursing, medicine, or public health are best served by reading the book as organized by chapters. Those who have a focus on medical anthropology may want to first read the Preface and Chapters One and Two, then skip to Chapters Six through Ten where classic paradigms of medical anthropology are covered: transcultural psychiatry, medical ecology, political and economic anthropology, symbolic healing, and shamanistic healing practices. Chapters Three through Five, which cover cultural competence, cultural systems analysis, and the sectors of health care, can be addressed last as specialty topics.

This book also has an audience in health care consumers. Fadiman tells us that she was transformed as a patient by learning of Lia Lee’s experiences. You, too, can be transformed as a consumer and patient by understanding the ways in which culture and its manifestations in the environment, power, and resources affect human health. Cultural and power perspectives can enable individuals to renegotiate the intercultural relations that are always part of medical encounters. Anthropological perspectives situate health in relationship to numerous environments where ecological, political, and symbolic factors have effects on health and care. A greater awareness of social and cultural contexts affecting health and health care make us better-informed providers and consumers.

“To future generations of health care professionals andmedical social scientists—that they may better understandthe roles of culture in health and well-being, and inthe care of patients and prevention of disease.”

THE AUTHOR

Michael Winkelman, Ph.D. (University of California-Irvine), M.P.H. (University of Arizona), is an associate professor in the School of Human Evolution and Social Change at Arizona State University and former head of Sociocultural Anthropology. For sixteen years, he directed the Ethnographic Field School in Ensenada, Baja California, Mexico. He taught for sixteen years in the California State University Statewide Nursing Program and currently teaches in the Arizona State University School of Nursing and Innovative Health Care. He was cofounder of the Arizona State University M.A. degree program in Cultural and Behavioral Dimensions of Health and served as director of the M.P.H. degree program. He served as president of the Anthropology of Consciousness section of the American Anthropological Association and was the founding president of its Anthropology of Religion section.

Winkelman has engaged in cross-cultural and interdisciplinary research on shamanism for the past thirty years, focusing principally on the cross-cultural patterns of shamanism and identifying the associated biological bases of shamanic universals and altered states of consciousness. His principal books on shamanism include Shamans, Priests and Witches (1992) and Shamanism: The Neural Ecology of Consciousness and Healing (2000). His textbooks for cross-cultural classes include American Ethnic History (2005) and Cultural Awareness, Sensitivity and Competence (2006). His recent work includes edited books on various aspects of healing: Pilgrimages and Healing (Dubisch and Winkelman, 2005), Divination and Healing: Potent Vision (Winkelman and Peek, 2004), and Psychedelic Medicine: New Evidence for Hallucinogen Substances as Treatments (Winkelman and Roberts, 2007). He has also explored the applications of shamanism to contemporary health problems of addiction (“Alternative and Complementary Medicine Approaches for Substance Abuse Programs: A Shamanic Perspective,” International Journal of Drug Policy (2001); and “Complementary Therapy for Addiction: ‘Drumming Out Drugs.’” American Journal of Public Health (2003). His forthcoming book with John Baker, Supernatural as Natural, addresses the biological bases of religion. He can be contacted at [email protected].

ACKNOWLEDGMENTS

I have benefited from the experiences with several groups of students whose sharing has assisted me in writing this text. These include particularly the nursing students of the California State University Statewide Nursing Program, whose papers exposed me to many practical dimensions of cultural knowledge in nursing care, and the Medicine, Culture and Healing Learning Community students at Arizona State University, who read an earlier version of this book and let me know where they did not understand what I was saying. I have also benefited from the papers and perspectives of the medical anthropology students at Arizona State University and the public health students in the University of Arizona-Arizona State University-Northern Arizona University Public Health Program. I particularly want to thank Sue, Cindy, and Eileen Winkelman for their assistance in the final preparation of the manuscript.

CHAPTER 1

APPLIED MEDICAL ANTHROPOLOGY AND HEALTH CARE

In improving patient satisfaction . . . administrators’ attentionis being directed to the impact of culture—of organization, roles,and values—upon overall quality of care and outcomes

—PRESS, 1997, P. 6

LEARNING OBJECTIVES

• Introduce how culture affects health

• Illustrate how anthropological perspectives can facilitate effective health care

• Introduce the nature of cultural competence in health care

• Illustrate medical anthropology’s major applications in addressing cultures’ impacts on health

• Illustrate the broad range of concerns people have with respect to their health

• Introduce the biopsychosocial framework for understanding diverse effects on health

• Present a cultural systems model for addressing factors that affect health

• Illustrate principal mechanisms of culture’s effects on health

CULTURE AND HEALTH

Have you ever felt when you went to the doctor that your problem wasn’t understood or that your treatment was not relevant to your health problem? Cultural differences between physicians and their diverse clients make cross-cultural misunderstandings inevitable. Culture affects patients’ and providers’ perceptions of health conditions and appropriate treatments. Culture also affects behaviors that expose us to disease and the reasons prompting us to seek care, how we describe our symptoms, and our compliance with treatments. This makes culture central to diagnosis and an important issue for all of the health professions.

Patients and providers need knowledge of the relationships of culture to health because culture is the foundation of everyone’s health concerns and practices. Improving health care requires attention to cultural influences on health concerns, conditions, beliefs, and practices. People’s health occurs within cultural systems that are concerned with broader issues of well-being than addressed by physicians’ concerns with disease and injury; we are also concerned with psychological, social, emotional, mental, and spiritual well-being. As biomedicine turns from a disease-focused approach to concepts with health and well-being, cultural perspectives and cultural competency emerge as central frameworks for improving care.

Medical anthropology is the primary discipline addressing the interfaces of medicine, culture, and health behavior and incorporating cultural perspectives into clinical settings and public health programs. Health professionals need knowledge of culture and cross-cultural relationship skills because health services are more effective when responsive to cultural needs. Cross-cultural skills also are important in relationships among providers of different cultures when, for example, African American and Filipino nurses interact with each other or with Anglo, Hispanic, or Hindu physicians. A knowledge of culture is also necessary for work in community settings, such as collaborating with diverse groups and organizations to develop culturally relevant public health programs. Health care providers and patients are more effective in managing their health and care with cultural awareness and the ability to manage the numerous factors that affect well-being.