Social Construction of Illness
As the above examples demonstrate, cultural attitudes affect how medical conditions will be perceived and how individuals with health problems will be regarded by the wider community. There is a difference, for instance, between a disease, which is a medical condition that can be objectively identified, and an illness, which is the subjective or personal experience of feeling unwell. Illnesses may be caused by disease, but the experience of being sick encompasses more than just the symptoms caused by the disease itself. Illnesses are, at least in part, social constructions: experiences that are given meaning by the relationships between the person who is sick and others.
The course of an illness can worsen for instance, if the dominant society views the sickness as a moral failing. Obesity is an excellent example of the social construction of illness. The condition itself is a result of culturally induced habits and attitudes toward food, but despite this strong cultural component, many people regard obesity as a preventable circumstance, blaming individuals for becoming overweight. This attitude has a long cultural history. Consider for instance the religious connotations within Christianity of “gluttony” as a sin.39 Such socially constructed stigma influences the subjective experience of the illness. Obese women have reported avoiding visits to physicians for fear of judgment and as a result may not receive treatments necessary to help their condition.40 Peter Attia, a surgeon and medical researcher who delivered a TED Talk on this subject, related the story of an obese woman who had to have her foot amputated, a common result of complications from obesity and diabetes. Even though he was a physician, he judged the woman to be lazy. “If you had just tried even a little bit,” he had thought to himself before surgery.
Subsequently, new research revealed that insulin resistance, a precursor to diabetes, often develops as a result of the excess sugars used in many kinds of processed foods consumed commonly in the United States. As Attia observes, high rates of obesity in the United States are a reflection of the types of foods Americans have learned to consume as part of their cultural environment.41 In addition, the fact that foods that are high in sugars and fats are inexpensive and abundant, while healthier foods are expensive and unavailable in some communities, highlights the economic and social inequalities that contribute to the disease.
The HIV/AIDS virus provides another example of the way that the subjective experience of an illness can be influenced by social attitudes. Research in many countries has shown that people, including healthcare workers, make distinctions between patients who are “innocent” victims of AIDS and those who are viewed as “guilty.” People who contracted HIV through sex or intravenous drug use are seen as guilty. The same judgment applies to people who contracted HIV through same-sex relationships in places where societal disapproval of same-sex relationships exists. People who contracted HIV from blood transfusions, or as babies, are viewed as innocent. The “guilty” HIV patients often find it more difficult to access medical care and are treated with disrespect or indifference in medical settings compared with superior treatment provided to those regarded as “innocent.” In the wider community, “guilty” patients suffer from social marginalization and exclusion while “innocent” patients receive greater social acceptance and practical assistance in responding to their needs for support and care.42
The stigma that applies to “guilty” patients also ignores the socioeconomic context in which HIV/AIDS spreads. For instance, in Indonesia, poor women can make considerably more money as sex workers than in many other jobs: $10 an hour as a sex worker compared to 20 cents an hour in a factory.43 In a similar way, poverty and a lack of other choices contribute to a decision to engage in sex work in other societies, including in sub-Saharan Africa where rates of HIV infection are among the highest in the world. Poverty itself is one of the greatest “risk factors” for HIV infection.44 The clear relationship between poverty, gender, and HIV infection has been the topic of a great deal of research in medical anthropology. One example is Paul Farmer’s classic book, AIDS and Accusation: Haiti and the Geography of Blame (1992), which was one of the earliest books to critically evaluate the connection between poverty, racism, stigma, and neglect that allowed HIV to infect and kill thousands of Haitians. Projects like this are critical to developing holistic views of the entire cultural, economic, and political context that affects the spread of the virus and attempts to treat the disease. Partners in Health, the non-profit medical organization Paul Farmer helped to found, continues to pursue innovative strategies to prevent and treat diseases like AIDS, strategies that recognize that poverty and social marginalization provide the environment in which the virus flourishes.
A culture-bound syndrome is an illness recognized only within a specific culture. These conditions, which combine emotional or psychological with physical symptoms, are not the result of a disease or any identifiable physiological dysfunction. Instead, culture-bound syndromes are somatic, meaning they are physical manifestations of emotional pain. The existence of these conditions demonstrates the profound influence of culture and society on the experience of illness.
Anorexia is considered a culture bound syndrome because of its strong association with cultures that place a high value on thinness as a measure of health and beauty. When we consider concepts of beauty from cultures all over the world, a common view of beauty is one of someone with additional fat. This may be because having additional fat in a place where food is expensive means that one is likely of a higher status. In societies like the United States where food is abundant, it is much more difficult to become thin than it is to become heavy. Although anorexia is a complex condition, medical anthropologists and physicians have observed that it is much more common in Western cultural contexts among people with high socioeconomic status.45 Anorexia, as a form of self-deprivation, has deep roots in Western culture and for centuries practices of self-denial have been associated with Christian religious traditions. In a contemporary context, anorexia may address a similar, but secular desire to assert self-control, particularly among teenagers.46
During her research in Fiji, Anne Becker (2004) noted that young women who were exposed to advertisements and television programs from Western cultures (like the United States and Australia) became self-conscious about their bodies and began to alter their eating habits to emulate the thin ideal they saw on television. Anorexia, which had been unknown in Fiji, became an increasingly common problem.47 The same pattern has been observed in other societies undergoing “Westernization” through exposure to foreign media and economic changes associated with globalization.48
Swallowing Frogs in Brazil
In Brazil, there are several examples of culture-bound syndromes that affect children as well as adults. Women are particularly susceptible to these conditions, which are connected to emotional distress. In parts of Brazil where poverty, unemployment, and poor physical health are common, there are cultural norms that discourage the expression of strong emotions such as anger, grief, or jealousy. Of course, people continue to experience these emotions, but cannot express them openly. Men and women deal with this problem in different ways. Men may choose to drink alcohol heavily, or even to express their anger physically by lashing out at others, including their wives. These are not socially acceptable behaviors for women who instead remark that they must suppress their feelings, an act they describe as having to “swallow frogs” (engolir sapos).49
Nervos (nerves) is a culture-bound syndrome characterized by symptoms such as headaches, trembling, dizziness, fatigue, stomach pain, tingling of the extremities and even partial paralysis. It is viewed as a result of emotional overload: a state of constant vulnerability to shock. Unexplained wounds on the body may be diagnosed as a different kind of illness known as “blood-boiling bruises.” Since emotion is culturally defined as a kind of energy that flows throughout the body, many believe that too much emotion can overwhelm the body, “boiling over” and producing symptoms. A person can become so angry, for instance, that his or her blood spills out from under the skin, creating bruises, or so angry that the blood rises up to create severe headaches, nausea, and dizziness. A third form of culture-bound illness, known as peito aberto (open chest) is believed to be occur when a person, most often a woman, is carrying too much emotional weight or suffering. In this situation, the heart expands until the chest becomes spiritually “open.” A chest that is “open” is dangerous because rage and anger from other people can enter and make a person sick.50
In stressful settings like the communities in impoverished areas of northeastern Brazil, it is common for people to be afflicted with culture-bound illnesses throughout their lives. Individuals can suffer from one condition, or a combination of several. Sufferers may consult rezadeiras/rezadores, Catholic faith healers who will treat the condition with prayer, herbal remedies, or healing rituals. Because these practitioners do not distinguish between illnesses of the body and mind, they treat the symptoms holistically as evidence of personal turmoil. This approach to addressing these illnesses is consistent with cultural views that it is the suppression of emotion itself that has caused the physical problems.