Ethnomedicine is the comparative study of cultural ideas about wellness, illness, and healing. For the majority of our existence, human beings have depended on the resources of the natural environment and on health and healing techniques closely associated with spiritual beliefs. Many such practices, including some herbal remedies and techniques like acupuncture, have been studied scientifically and found to be effective.13 Others have not necessarily been proven medically effective by external scientific evidence, but continue to be embraced by communities that perceive them to be useful. When considering cultural ideas about health, an important place to start is with ethno-
etiology: cultural explanations about the underlying causes of health problems.
In the United States the dominant approach to thinking about health is biomedical. Illnesses are thought to be the result of specific, identifiable agents. This can include pathogens (viruses or bacteria), malfunction of the body’s biochemical processes (conditions such as cancer), or physiological disorders (such as organ failure). In biomedicine as it is practiced in the United States (Western biomedicine), health is defined as the absence of disease or dysfunction, a perspective that notably excludes consideration of social or spiritual well-being. In non-Western contexts biomedical explanations are often viewed as unsatisfactory. In his analysis of ideas about health and illness in non-Western cultures, George Foster (1976) concluded that these ideas could be categorized into two main types of ethno-etiology: personalistic and naturalistic.14
Ethno-Etiologies: Personalistic and Naturalistic
Personalistic ethno-etiologies view disease as the result of the “active, purposeful intervention of an agent, who may be human (a witch or sorcerer), nonhuman (a ghost, an ancestor, an evil spirit), or supernatural (a deity or other very powerful being).”15 Illness in this kind of ethno-etiology is viewed as the result of aggression or punishment directed purposefully toward an individual; there is no accident or random chance involved. Practitioners who are consulted to provide treatment are interested in discovering who is responsible for the illness—a ghost, an ancestor? No one is particularly interested in discovering how the medical condition arose in terms of the anatomy or biology involved. This is because treating the illness will require neutralizing or satisfying a person, or a supernatural entity, and correctly identifying the being who is the root cause of the problem is essential for achieving a cure.
The Heiban Nuba people of southern Sudan provide an interesting example of a personalistic etiology. As described by, S.F. Nadel in the 1940s, the members of this society had a strong belief that illness and other misfortune was the result of witchcraft.
A certain magic, mysteriously appearing in individuals, causes the death or illness of anyone who eats their grain or spills their beer. Even spectacular success, wealth too quickly won, is suspect; for it is the work of a spirit-double, who steals grain or livestock for his human twin. This universe full of malignant forces is reflected in a bewildering array of rituals, fixed and occasional, which mark almost every activity of tribal life.16
Because sickness is thought to be caused by spiritual attacks from others in the community, people who become sick seek supernatural solutions. The person consulted is often a shaman, a person who specializes in contacting the world of the spirits.
In Heiban Nuba culture, as well as in other societies where shamans exist, the shaman is believed to be capable of entering a trance-like state in order to cross between the ordinary and supernatural realms. While in this state, the shaman can identify the individual responsible for causing the illness and sometimes the spirits can be convinced to cure the disease itself. Shamans are common all around the world and despite the proverbial saying that “prostitution is the oldest profession,” shamanism probably is! Shamans are religious and medical practitioners who play important social roles in their communities as healers with a transcendent ability to navigate the spirit world for answers. In addition, the often have a comprehensive knowledge of the local ecology and how to use plants medicinally. They can address illnesses using both natural and supernatural tools.
In naturalistic ethno-etiologies, diseases are thought to be the result of natural forces such as “cold, heat, winds, dampness, and above all, by an upset in the balance of the basic body elements.”17 The ancient Greek idea that health results from a balance between the four humors is an example of a naturalistic explanation. The concept of the yin and yang, which represent opposite but complementary energies, is a similar idea from traditional Chinese medicine. Achieving balance or harmony between these two forces is viewed as essential to physical and emotional health. Unlike personalistic explanations, practitioners who treat illness in societies with naturalistic ethno-etiologies are interested in understanding how the medical condition arose so that they can choose therapeutic remedies viewed as most appropriate.
Emotional difficulties can be viewed as the cause of illness in a naturalistic ethno-etiology (an emotionalistic explanation). One example of a medical problem associated with emotion is susto, an illness recognized by the Mixe, an indigenous group who live in Oaxaca, Mexico, as well as others throughout central America. The symptoms of susto include difficulty sleeping, lack of energy, loss of appetite and sometimes nausea/vomiting and fever. The condition is believed to be a result of a “fright” or shock and, in some cases at least, it is believed to begin with a shock so strong that it disengages the soul from the body.18 The condition is usually treated with herbal remedies and barrida (sweeping) ceremonies designed to repair the harm caused by the shock itself.19 Although physicians operating within a biomedical ethno-etiology have suggested that susto is a psychiatric illness that in other cultural contexts could be labeled anxiety or depression, in fact susto is does not fit easily into any one Western biomedical category. Those suffering from susto see their condition as a malady that is emotional, spiritual, and physical.20
In practice, people assess medical problems using a variety of explanations and in any given society personalistic, naturalistic, or even biomedical explanations may all apply in different situations. It is also important to keep in mind that the line between a medical concern and other kinds of life challenges can be blurry. An illness may be viewed as just one more instance of general misfortune such as crop failure or disappointment in love. Among the Azande in Central Africa, witchcraft is thought to be responsible for almost all misfortune, including illness. E.E. Evans-Pritchard, an anthropologist who studied the Azande of north-central Africa in the 1930s, famously described this logic by describing a situation in which a granary, a building used to store grain, collapsed.
In Zandeland sometimes an old granary collapses. There is nothing remarkable in this. Every Zande knows that termites eat the supports in course of time and that even the hardest woods decay after years of service. Now a granary is the summerhouse of a Zande homestead and people sit beneath it in the heat of the day and chat or play the African hole-game or work at some craft. Consequently it may happen that there are people sitting beneath the granary when it collapses and they are injured…Now why should these particular people have been sitting under this particular granary at the particular moment when it collapsed? That it should collapse is easily intelligible, but why should it have collapsed at the particular moment when these particular people were sitting beneath it…The Zande knows that the supports were undermined by termites and that people were sitting beneath the granary in order to escape the heat of the sun. But he knows besides why these two events occurred at a precisely similar moment in time and space. It was due to the action of witchcraft. If there had been no witchcraft people would have been sitting under the granary and it would not have fallen on them, or it would have collapsed but the people would not have been sheltering under it at the time. Witchcraft explains the coincidence of these two happenings.21
According to this logic, an illness of the body is ultimately caused by the same force as the collapse of the granary: witchcraft. In this case, an appropriate treatment may not even be focused on the body itself. Ideas about health are often inseparable from religious beliefs and general cultural assumptions about misfortune.22
Is Western Biomedicine An Ethno-Etiology?
The biomedical approach to health strikes many people, particularly residents of the United States, as the best or at least the most “fact-based” approach to medicine. This is largely because Western biomedicine is based on the application of insights from science, particularly biology and chemistry, to the diagnosis and treatment of medical conditions. The effectiveness of biomedical treatments is assessed through rigorous testing using the scientific method and indeed Western biomedicine has produced successful treatments for many dangerous and complex conditions: everything from antibiotics and cures for cancer to organ transplantation.
However, it is important to remember that the biomedical approach is itself embedded in a distinct cultural tradition, just like other ethno-etiologies. Biomedicine, and the scientific disciplines on which it is based, are products of Western history. The earliest Greek physicians Hippocrates (c. 406–370 BC) and Galen (c. 129–c. 200 AD) shaped the development of the biomedical perspective by providing early insights into anatomy, physiology, and the relationship between environment and health. From its origins in ancient Greece and Rome, the knowledge base that matured into contemporary Western biomedicine developed as part of the Scientific Revolution in Europe, slowly maturing into the medical profession recognized today. While the scientific method used in Western biomedicine represents a distinct and powerful “way of knowing” compared to other etiologies, the methods, procedures, and forms of reasoning used in biomedicine are products of Western culture. 23
In matters of health, as in other aspects of life, ethnocentrism predisposes people to believe that their own culture’s traditions are the most effective. People from non-Western cultures do not necessarily agree that Western biomedicine is superior to their own ethno-etiologies. Western culture does not even have a monopoly on the concept of “science.” Other cultures recognize their own forms of science separate from the Western tradition and these sciences have histories dating back hundreds or even thousands of years. One example is Traditional Chinese Medicine (TCM), a set of practices developed over more than 2,500 years to address physical complaints holistically through acupuncture, exercise, and herbal remedies. The tenets of Traditional Chinese Medicine are not based on science as it is defined in Western culture, but millions of people, including a growing number of people in the United States and Europe, regard TCM as credible and effective.
Ultimately, all ethno-etiologies are rooted in shared cultural perceptions about the way the world works. Western biomedicine practitioners would correctly observe that the strength of Western biomedicine is derived from use of a scientific method that emphasizes objectively observable facts. However, this this would not be particularly persuasive to someone whose culture uses a different ethno-etiology or whose understanding of the world derives from a different tradition of “science.” From a comparative perspective, Western biomedicine may be viewed as one ethno-etiology in a world of many alternatives.
Techniques for Healing
Western biomedicine tends to conceive of the human body as a kind of biological machine. When parts of the machine are damaged, defective, or out of balance, chemical or surgical interventions are the preferred therapeutic responses. Biomedical practitioners, who can be identified by their white coats and stethoscopes, are trained to detect observable or quantifiable symptoms of disease, often through the use of advanced imaging technologies or tests of bodily fluids like blood and urine. Problems detected through these means will be addressed. Other factors known to contribute to wellness, such as the patient’s social relationships or emotional state of mind, are considered less relevant for both diagnosis and treatment. Other forms of healing, which derive from non-biomedical ethno-etiologies, reverse this formulation, giving priority to the social and spiritual.
In Traditional Chinese Medicine, the body is thought to be governed by the same forces that animate the universe itself. One of these is chi (qi), a vital life force that flows through the body and energizes the body and its organs. Disruptions in the flow or balance of chi can lead to a lack of internal harmony and ultimately to health problems so TCM practitioners use treatments designed to unblock or redirect chi, including acupuncture, dietary changes, and herbal remedies. This is an example of humoral healing, an approach to healing that seeks to treat medical ailments by achieving a balance between the forces or elements of the body.
Communal healing, a second category of medical treatment, directs the combined efforts of the community toward treating illness. In this approach, medical care is a collaboration between multiple people. Among the !Kung (Ju/’hoansi) of the Kalahari Desert in southern Africa, energy known as n/um can be channeled by members of the community during a healing ritual and directed toward individuals suffering from illness. Richard Katz, Megan Bisele, and Verna St. Davis (1982) described an example of this kind of ceremony:
The central event in this tradition is the all-night healing dance. Four times a month on the average, night signals the start of a healing dance. The women sit around the fire, singing and rhythmically clapping. The men, sometimes joined by the women, dance around the singers. As the dance intensifies, n/um, or spiritual energy, is activated by the healers, both men and women, but mostly among the dancing men. As n/um is activated in them, they begin to kia, or experience an enhancement of their consciousness. While experiencing kia, they heal all those at the dance.24
While communal healing techniques often involve harnessing supernatural forces such as the num, it is also true that these rituals help strengthen social bonds between people. Having a strong social and emotional support system is an important element of health in all human cultures.
Faith and the Placebo Effect
Humoral and communal approaches to healing, which from a scientific perspective would seem to have little potential to address the root causes of an illness, present an important question for medical anthropologists. What role does faith play in healing? Sir William Osler, a Canadian physician who was one of the founders of Johns Hopkins Hospital, believed that much of a physician’s healing ability derived from his or her ability to inspire patients with a faith that they could be cured.25 Osler wrote:
Faith in the Gods or in the Saints cures one, faith in little pills another, suggestion a third, faith in a plain common doctor a fourth…If a poor lass, paralyzed apparently, helpless, bed-ridden for years, comes to me having worn out in mind, body, and estate a devoted family; if she in a few weeks or less by faith in me, and faith alone, takes up her bed and walks, the Saints of old could not have done more.26
In fact, there is a considerable amount of research suggesting that there is a placebo effect involved in many different kinds of healing treatments. A placebo effect is a response to treatment that occurs because the person receiving the treatmentbelieves it will work, not because the treatment itself is effective.
In Western biomedicine, the placebo effect has been observed in situations in which a patient believes that he or she is receiving a certain drug treatment, but is actually receiving an inactive substance such as water or sugar. 27 Research suggests that the body often responds physiologically to placebos in the same way it would if the drug was real.28 The simple act of writing a prescription can contribute to the successful recovery of individuals because patients trust that they are on a path that will lead to wellness.29 If we consider the role of the placebo effect in the examples above, we should consider the possibility that humoral and communal healing are perceived to “work” because the people who receive these remedies have faith in them.
An interesting example of the complexity of the mind-body connection is found in studies of intercessory prayer: prayers made to request healing for another person. In one well-known study, researchers separated patients who had recently undergone heart surgery into two groups, one containing people who know they would be receiving prayers for their recovery and another group who would receive prayers without being aware of it. Those patients who knew they were receiving prayers actually had more complications and health problems in the month following surgery.30 This reflects an interesting relationship between faith and healing. Why did the patients who knew that others were praying for them experience more complications? Perhaps it was because the knowledge that their doctors had asked others to pray for them made patients more stressed, perceiving that their health was at greater risk.
However, it can also be a lack of faith that drives people to look for alternative treatments. In the United States, alternative treatments, some of which are drawn from humoral or communal healing traditions, have become more popular among patients who believe that Western biomedicine is failing them. Cancer research facilities have begun to suggest acupuncture as a treatment for the intense nausea and fatigue caused by chemotherapy and scientific studies suggest that acupuncture can be effective in relieving these symptoms.31 Marijuana, a drug that has a long recorded history of medical use starting in ancient China, Egypt, and India, has steadily gained acceptance in the United States as a treatment for a variety of ailments ranging from anxiety to Parkinson’s disease.32 As growing numbers of people place their faith in these and other remedies, it is important to recognize that many alternative forms of healing or medicine lack scientific evidence for their efficacy. The results derived from these practices may owe as much to faith as medicine.
Unlike other kinds of illnesses, which present relatively consistent symptoms and clear biological evidence, mental health disorders are experienced and treated differently cross-culturally. While the discipline of psychiatry within Western biomedicine applies a disease-framework to explain mental illness, there is a consensus in medical anthropology that mental health conditions are much more complicated than the biological illness model suggests. These illnesses are not simply biological or chemical disorders, but complex responses to the environment, including the web of social and cultural relationships to which individuals are connected.
Medical anthropologists do not believe there are universal categories of mental illness.33 Instead, individuals may express psychological distress through a variety of physical and emotional symptoms. Arthur Kleinman, a medical anthropologist, has argued that every culture frames mental health concerns differently. The pattern of symptoms associated with mental health conditions vary greatly between cultures. In China, Kleinman discovered that patients suffering from depression did not describe feelings of sadness, but instead complained of boredom, discomfort, feelings of inner pressure, and symptoms of pain, dizziness, and fatigue.34
Mental health is closely connected with social and cultural expectations and mental illnesses can arise as a result of pressures and challenges individuals face in particular settings. Rates of depression are higher for refugees, immigrants, and others who have experienced dislocation and loss. A sense of powerlessness also seems to play a role in triggering anxiety and depression, a phenomenon that has been documented in groups ranging from stay-at-home mothers in England to Native Americans affected by poverty and social marginalization.35
Schizophrenia, a condition with genetic as well as environmental components, provides another interesting example of cross-cultural variation. Unlike anxiety or depression, there is some consistency in the symptom patterns associated with this condition cross culturally: hallucinations, delusions, and social withdrawal. What differs, however, is the way these symptoms are viewed by the community. In his research in Indonesia, Robert Lemelson discovered that symptoms of schizophrenia are often viewed by Indonesian communities as examples of communication with the spirit world, spirit possession, or the effects of traumatic memories.36 Documenting the lives of some of these individuals in a film series, he noted that they remained integrated into their communities and had significant responsibilities as members of their families and neighborhoods. People with schizophrenia were not, as often happens in the United States, confined to institutions and many were living with their condition without any biomedical treatments.
In its multi-decade study of schizophrenia in 19 countries, the World Health Organization concluded that societies that were more culturally accepting of symptoms associated with schizophrenia integrated people suffering from the condition into community life more completely. In these cultures, the illness was less severe and people with schizophrenia had a higher quality of life.37 This finding has been controversial, but suggests that stigma and the resulting social isolation that characterize responses to mental illness in countries like the United States affect the subjective experience of the illness as well as its outcomes.38