I did cut out all the grading and policy details.  If you’re really interested in that, drop me an email.

Anthropology 5937: Biocultural Medical Anthropology

Prof. Daniel Lende, Fall 2010, University of South Florida

Content:

This course provides a comprehensive grounding in biocultural medical anthropology, which emphasizes understanding how health and healing are shaped by both biological and cultural processes.  This class will examine disease, illness, human biology, embodiment, public health, methods, and belief systems.  From the biology of stress to the biopolitics of medicine, students will engage in substantive discussion and read central pieces of the scientific and anthropological literature.  While the class is focused on biocultural dynamics, students will also cover the biological mechanisms of disease and applied biocultural practice.

Required Texts:

Wiley, Andrea & Allen, John. 2009. Medical Anthropology: A Biocultural Approach.  New York: Oxford University Press.

Nichter, Mark. 2008. Global Health: Why Cultural Perceptions, Social Representations, and Biopolitics Matter. Tucson: University of Arizona Press.

Knapp, Caroline. 1997. Drinking: A Love Story. New York: Dial.

Schedule of Classes and Readings

Week One

Aug 24: Introduction to Class

Book: None    

Aug 26: Biocultural Perspectives on Health & Disease

Book: Wiley & Allen, Ch 1-2

Reading:

- R. Hahn & M. Inhorn. 2009. Introduction. In: Anthropology and Public Health: Bridging Differences in Culture and Society, Second Edition. Pp. 1-31.

Recommended

- G. Armelagos et al. 2005. Evolutionary, historical and political economic perspectives on health and disease. Social Science and Medicine 61(4):755-765.

-A. McElvoy & P. Townsend. 2009. Interdisciplinary research in health problems. In: Medical Anthropology in Ecological Perspective, 5^th Edition. Pp. 33-80.

-P. Farmer et al. 2006. Structural violence and clinical medicine. PLoS Medicine 3(10): e449.

-A. Kleinman. 2010. The art of medicine: Four social theories for global health.  Lancet 375:1518-19.

-S. McGarvey. 2007. Population health. Annals of Human Biology 34(4):393-396.

-R. Nesse. 2008. Evolution: Medicine’s most basic science. The Lancet 372: S21-S27.

Week Two

Aug 31: Diet & Nutrition

Book: Wiley & Allen, Ch 4

Reading:

-D. Himmelgreen & N. Romero Daza. In press. Nutrition. In M. Singer & PI Anderson, eds., Companion to Medical Anthropology.

-T. Leatherman. 2005. A space of vulnerability in poverty and health: Political-ecology and biocultural analysis. Ethos 33(1): 46-70.

Recommended

- C. Victora et al. 2008. Maternal and child undernutrition: Consequences for adult health and human capital. Lancet 371(9609): 340-357.

- B. Turner et al. 2007. Human evolution, diet, and nutrition: When the body meets the buffet. In: Evolutionary Medicine and Health. Pp. 55-71.

Sep 2: Growth & Development

Book: Wiley & Allen, Ch 5

Reading:

- C. Worthman. 1999. The epidemiology of human development. In: C. Panter Brick and C.M. Worthman, eds. Hormones, Health, and Behavior. Pp. 47-104.  

- N. Krieger & G. Davey Smith. 2004. “Bodies count,” and body counts: social epidemiology and embodying inequality. Epidemiologic Reviews 26: 92-103.

Recommended

-S. Stinson. 2000. Growth variation: Biological and cultural factors. In: Human Biology: An Evolutionary and Biocultural Perspective. Pp. 425-463.

- J. Hoddinot et al. 2008. Effect of a nutrition intervention during early childhood on economic productivity in Guatemalan adults. Lancet 371: 411-416.

- K. Hampshire et al. 2009. Saving lives, preserving livelihoods: Understanding risk, decision-making and child health in a food crisis. Social Science & Medicine 68(4):758-765.

Week Three

Sep 7: Inequality

Book: None

Reading:

- R. Wilkinson. 2006. The impact of inequality. Social Research 73(2): 711-732.

- M. Marmot M. 2007. Achieving health equity: From root causes to fair outcomes. Lancet 370: 1153-63.

- C. Hertzman & T. Boyce. 2010. How experience gets under the skin to create gradients in developmental health. Annual Review of Public Health 31: 329-347.

Recommended

- N. Adler & J. Stewart. 2010. Health disparities across the lifespan: Meanings, methods and mechanisms. Annals of the New York Academy of Sciences 1186:5-23.

- C. Kuzawa & E. Quinn. 2009. Developmental origins of adult function and health: Evolutionary hypotheses. Annual Review of Anthropology 38:131-147.

Sep 9: Reproductive Health

Book: Wiley & Allen, Ch 6

Reading:

- M. Lock & V. Nguyen. 2010. Local biologies and human difference. In: An Anthropology of Biomedicine. Pp. 83-110.

- K. Oths. 1999 Debilidad: A biocultural assessment of an embodied Andean illness.  Medical Anthropology Quarterly 13(3):286-315.

Recommended

- M. Tapias. 2006. Emotions and the intergenerational embodiment of social suffering in rural Bolivia. Medical Anthropology Quarterly 20(3): 399-415.

- D. Lende & A. Lachiondo. 2009. Embodiment and breast cancer among African-American women. Qualitative Health Research 19: 216-228.

- B. Piperata. 2008. Forty days and forty nights: A biocultural perspective on postpartum practices in the Amazon. Social Science & Medicine 67: 1094–1103.

Week Four

Sep 14: Aging

Book: Wiley & Allen, Ch 7

Reading:

- C. Ikels. 1998. The experience of dementia in China. Culture, Medicine and Psychiatry 22(3): 257-283.

- P. Kontos. 2006. Embodied selfhood: An ethnographic exploration of Alzheimer’s disease. In: Thinking about Dementia, Leibing and Cohen eds. Pp. 195-217.

Due: Revision of Wiki Entry

Recommended

-D. Crews & B. Bogin. 2010. Development, senescence and aging. In Clark Spencer Larsen, ed., A Companion to Biological Anthropology. Pp. 124-153.

 - P. Kontos & G. Naglie. 2009. Tacit knowledge of caring and embodied selfhood. Sociology of Health and Illness 31(5): 688-704.

Sep 16: Infectious Disease: Pathogens & Immunity

Book: Wiley & Allen, Ch 8

Reading:

- T. McDade. 2005.  The ecologies of human immune function. Annual Review of Anthropology 34: 495-521.

- P. Brown, M. Inhorn & D. Smith. 1996. Disease, ecology, and human behavior. In: Medical Anthropology: Contemporary Theory and Method, Revised Edition. Pp. 183-218.

Recommended

- J. Eisenberg et al. 2006. Environmental change and infectious disease: How new roads affect the transmission of diarrheal pathogens in rural Ecuador. Proceedings of the National Academy of Sciences 103(51): 19460-19465.

- K. Smith & N. Christakis. 2008. Social networks and health. Annual Review of Sociology 34: 405-429.

Week Five

Sep 21: Infectious Disease: Globalization

Book: Wiley & Allen, Ch 9

Reading:

-R. Barrett et al. 1998. Emerging and reemerging infectious diseases: The third epidemiological transition. Annual Review of Anthropology 27:247-271.

- Farmer, P. 1999.  Rethinking “emerging infectious diseases” (ch.2) and Immodest claims of causality (ch. 10) In Infections and Inequalities. Pp. 37-58 and 228-261.

Due: Draft of Wiki Entry

Recommended

-L. Manderson et al. 2009. Social research on neglected diseases of poverty: Continuing and emerging themes. PLoS Neglected Tropical Diseases 3(2): e332.

- E. Anderson-Fye. 2004. A “Coca-Cola” shape: Cultural change, body image, and eating disorders in San Andrés, Belize. Culture, Medicine & Psychiatry 28(4): 561-595.

Sept 23: Emerging Diseases: Malaria & HIV

Book: Wiley & Allen, Ch 10

Reading:

-H. Williams & C. Jones. 2004. A critical review of behavioral issues related to malaria control in sub-Saharan Africa: What contributions have social scientists made? Social Science and Medicine 59(3): 501-523.

-P. Farmer et al. 2001. Community-based approaches to HIV treatment in resource poor settings. Lancet 358: 404-409.

Recommended

- V. Kamat. 2008. Dying under the bird’s shadow: Narrative representations of degedege and child survival among the Zaramo of Tanzania. Medical Anthropology Quarterly 22(1): 67-93.

Week Six

Sep 28: Stress & Social Inequality

Book: Wiley & Allen, Ch 11

Reading:

-R. Sapolsky. 2005. The influence of social hierarchy on primate health. Science 308(5722):648-652.

-T. McDade. 2008. Beyond the gradient: An integrative anthropological perspective on social stratification, stress, and health. In C. Panter-Brick & A. Fuentes, eds., Health, Risk and Adversity. Pp. 209-235.

Recommended

-N. Schoenberg et al. 2009. Situating stress: Lessons from lay discourses on diabetes. In: Anthropology and Public Health: Bridging Differences in Culture and Society, Second Edition. Pp. 94-113.

-E. Mendenhall et al. 2010. Speaking through diabetes: Rethinking the significance of lay discourses on diabetes. Medical Anthropology Quarterly 24(2): 220-239.

- M. Nichter. 1981. Idioms of distress: Alternatives in the expression of psychosocial distress: A case study from South India. Culture, Medicine & Psychiatry, 5(4), 379-408.

-R. Sapolsky. 2004. Immunity, stress and disease. In: Why Zebras Don’t Get Ulcers. Pp. 144-185.

- W. Dressler. 2004. Culture and the risk of disease. British Medical Bulletin 69: 21-31.

- M. Flinn. 2007. Why words can hurt us: Social relationships, stress, and health. In: Evolutionary Medicine and Health. Pp. 242-258.

Sep 30: The Impact of Race – Genetics or Experience?

Book: None

Reading:

- A. Goodman. 2000. Why genes don’t count (for racial differences in health). American Journal of Public Health 90(11):1669-1702.

-C. Gravlee et al. 2009. Genetic ancestry, social classification, and racial inequalities in blood pressure in southeastern Puerto Rico. PLoS One 4(9): e6821.

Due: New Wiki Entry

Recommended

-C. Gravlee. 2009. How race becomes biology: Embodiment of social inequality. American Journal of Physical Anthropology 139(1): 47-57.

-N. Krieger. 2010. The science and epidemiology of racism and health: Racial/ethnic categories, biological expressions of race, and the embodiment of inequality – an ecosocial perspective. In: What’s the Use of Race? Modern Governance and the Biology of Difference. Pp. 225-256.

- A. Kleinman. 2000. The violence of everyday life: The multiple forms and dynamics of social violence. In Violence and Subjectivity. Veena Das et al., eds. Pp. 226-241.

Week Seven

Oct 5: Mental Health

Book: Wiley & Allen, Ch 12

Reading:

-W. Dressler et al. 2007. Cultural consonance and psychological distress: Examining the associations in multiple cultural domains. Culture, Medicine and Psychiatry 31(2): 195-224.

-R. Seligman & L. Kirmayer. 2008. Dissociative experience and cultural neuroscience: Narrative, metaphor and mechanism. Culture, Medicine and Psychiatry 32(1): 31-64.

Recommended

- L. Weaver & C. Hadley. 2009. Moving beyond hunger and nutrition: A systematic review of the evidence linking food insecurity and mental health in developing countries. Ecology of Food and Nutrition 48(4): 263-284.

- M. Eggerman & C. Panter-Brick. 2010.  Suffering, hope, and entrapment: Resilience and cultural values in Afghanistan.  Social Science & Medicine 71:71-83.

- B. Pescosolido, C. Brooks Gardner & K. Lubell. 1998. How people get into mental health services: Stories of choice, coercion and muddling through from first-timers. Social Science and Medicine 46 (2): 275-286.

Oct 7: Neuroanthropology

Book: None

Reading:

-G. Downey & D. Lende. 2009. The encultured brain: Why neuroanthropology? Why now? http://neuroanthropology.net/2009/10/08/the-encultured-brain-why-neuroanthropology-why-now/

-M. Cameron Hay. 2009. Anxiety, remembering, and agency: Biocultural insights for understanding Sasaks’ responses to illness. Ethos 37(1): 1-31.

-G. Downey. 2010. ‘Practice without theory’: a neuroanthropological perspective on embodied learning. Journal of the Royal Anthropological Institute 16: S22-S40.

Recommended

- J. Dumit. 2003. Is it me or my brain? Journal of Medical Humanities 24:35-47.

-S. Choudhury et al. 2009. Critical neuroscience: Linking neuroscience and society through critical practice. BioSocieties 4: 61-77.

-B. Kohrt. 2005. “Somatization” and “comorbidity”: A study of Jhum-Jhum and depression in rural Nepal. Ethos 33(1): 125-147.

-C. Worthman. 2009. Habits of the heart: Life history and the developmental neuroendocrinology of emotion. American Journal of Human Biology 21(6): 772-781.

Week Eight

Oct 12: The Relevance of Medical Anthropology

Book: Wiley & Allen, Epilogue

Reading:

-C. Worthman & B. Kohrt. 2005. Receding horizons of health: Biocultural approaches to public health paradoxes. Social Science and Medicine 61(4): 861-878.

-C. Hemmings. 2005. Rethinking medical anthropology: How anthropology is failing medicine. Anthropology and Medicine 12(2): 91-103.

Due: All Wiki Revisions

Recommended

- D. Napolitano & C. Jones. 2006. Who needs ‘pukka’ anthropologists’? A study of the perceptions of the use of anthropology in tropical public health research. Tropical Medicine and International Health 11(8): 1264-1275.

 - A. Wiley. 2004. Toward relevant research: Adaptation and policy perspectives on maternal-infant health in Ladakh. In: An Ecology of High-Altitude Infancy: A Biocultural Perspective. Pp. 178-203.

Oct 14: Methods in Biocultural Anthropology

Book: None

Reading:

- C. Worthman & E. Costello. 2009. Tracking biocultural pathways to health disparities: The value of biomarkers. Annals of Human Biology 36(3): 281-297.

-D. Hruschka. 2009. Culture as an explanation in population health. Annals of Human Biology 36(3): 235-247.

-C. Hadley & A. Wutich. 2009. Experience-based measures of food and water security: Biocultural approaches to grounded measures of insecurity. Human Organization 68(4): 451-460.

Recommended

-C. Gravlee et al. 2009. Methods for collecting panel data: What can cultural anthropology learn from other disciplines? Journal of Anthropological Research 65(3): 453-483.

- J. Limon. 1989. Carne, carnales, and the carnivalesque: Bakhtinian batos, disorder, and narrative discourses. American Ethnologist 16(3): 471-486.

Week Nine

Oct 19: Healing

Book: Wiley & Allen, Ch 3

Reading:

-T. Csordas & A. Kleinman. 1996. The therapeutic process. In Handbook of Medical Anthropology. Pp. 3-20.

-J. Frank & J. Frank. 1986. Therapeutic components shared by all psychotherapies. In: Cognition and Psychotherapy, A. Freeman et al., eds. Pp. 45-78.

Due: Initial Draft of PLoS Post

Recommended

- K. Finkler. 1994.  Sacred healing and biomedicine compared. Medical Anthropology Quarterly 8(2):178-197

- M. Nichter & C. Nordstrom.  1989.  A question of medicine answering: Health commodification and the social relations of healing in Sri Lanka. Culture, Medicine & Psychiatry 13: 367-390.

Oct 21: Ethnophysiology & Embodiment

Book: Nichter, Intro, Ch 1

Reading:

-C. Helman. 2007. The body: Cultural definitions of anatomy and physiology. In: Culture, Health and Illness, Fifth Edition.

- G. Shepard. 2004. A sensory ecology of medicinal plant therapy in two Amazonian societies. American Anthropologist 106(2): 252-266.

Recommended

- M. Lock & N. Scheper-Hughes. 1996. A critical-interpretive approach in medical anthropology: Rituals and routines of discipline and dissent. In: Medical Anthropology: Contemporary Theory and Method, Revised Edition.

- N. Krieger. 2005. Embodiment: a conceptual glossary for epidemiology. Journal of Epidemiology and Community Health 59(5): 350-355.

-L. Kirmayer. 1992. The body’s insistence on meaning: Metaphor as presentation and representation in illness experience. Medical Anthropology Quarterly 6(4): 323-346.

Week Ten

Oct 26: Illness Causality & Categories

Book: Nichter, Ch 2-3

Reading:

- L. Rebhun. 1994. Swallowing frogs: Anger and illness in Northeast Brazil. Medical Anthropology Quarterly 8(4): 360-382.

- P. Farmer. 1999. Sending sickness: Sorcery, politics, and changing concepts of AIDS in rural Haiti. In: Infections and Inequalities. Pp. 158-183.

Recommended

- R. Baer, L. Clark, & C. Peterson. 1998. Folk illnesses. In: Louie S, ed. Handbook of Immigrant Health.  Pp. 183-202.

- L. Garro. 2000. Cultural meaning, explanations of illness, and the development of comparative frameworks. Ethnology 39(4):305-334.

- L. Chavez et al. 2001. Beliefs matter: cultural beliefs and the use of cervical cancer-screening tests. American Anthropologist 103(4), 1114-1129.

Oct 28: Pharmaceuticals & Placebos

Book: Nichter, Ch 4

Reading:

-D. Moerman & W. Jonas. 2002. Deconstructing the placebo effect and finding the meaning response. Annals of Internal Medicine 136: 471-476.

-S. Reynolds White et al. 2002. Mothers and children: The efficacies of drugs. In: Social Lives of Medicines. Pp. 23-36.

Recommended

- J. Thompson et al. 2009. Reconsidering the placebo response from a broad anthropological perspective. Culture, Medicine and Psychiatry 33(1): 112-152.

- S. Van der Geest & S. Reynolds Whyte. 1989. The charm of medicine: Metaphors and metonyms. Medical Anthropology Quarterly 3(4): 325-344.

Week Eleven

Nov 2: Health Policy & Biomedicine Reconsidered

Book: Nichter, Ch 5-6

Reading:

-A. Castro & P. Farmer. 2005. Understanding and addressing AIDS-related stigma: From anthropological theory to clinical practice. American Journal of Public Health 95(1): 53-59.

-M. Rotherham-Borus et al. 2009. Common factors in effective HIV prevention programs. AIDS and Behavior 13: 399-408.

Recommended

- M. Nichter. 2002. The social relations of therapy management.  New Horizons in Medical Anthropology, M. Nichter and M. Lock, eds. Pp. 81-110.

- B. Good. 1994.  Medical anthropology and the problem of belief.  In: Medicine, Rationality and Experience. Pp. 1-24.

- L. Hunt. 2000. Strategic suffering: Illness narratives as social empowerment among Mexican cancer patients. In: Narrative and the Cultural Construction of Illness and Healing. Garro and Mattingly eds. Pp. 88-107.

- C. Briggs. 2003. Why nation-states and journalists can’t teach people to be healthy: power and pragmatic miscalculation in public discourses on health. Medical Anthropology Quarterly 17(3): 287-321.

Nov 4: NGOs to Policy

Book: Nichter, Ch 7-8

Reading:

- M. Lock & V. Nguyen. 2010. Biomedical technologies in practice. In: An Anthropology of Biomedicine. Pp. 17-31.

- V. Smith-Oka. 2009. Unintended consequences: Exploring the tensions between development programs and indigenous women in Mexico in the context of reproductive health. Social Science & Medicine 68(11): 2069-2077.

Due: Proposal for Poster/Final Paper Project

Recommended

- D. Mosse. 2004. Is good policy unimplementable? Reflections on the ethnography of aid policy and practice. Development and Change 35(4): 639-671.

- L. Schell et al. 2007. Advancing biocultural models by working with communities: A partnership approach. American Journal of Human Biology 19(4): 511-524.

- S. McGarvey. 2009. Interdisciplinary translational research in anthropology, nutrition, and public health. Annual Review of Anthropology 38(1): 233-249.

Week Twelve

Nov 9: Biopolitics and Biopower

Book: None

Reading:

- M. Lock & V. Nguyen. 2010. Who owns the body? In: An Anthropology of Biomedicine. Pp. 205-228.

- J. Biehl. 2010. Human pharmakon: Symptoms, technologies, subjectivities. In: A Reader in Medical Anthropology: Theoretical Trajectories, Emergent Realities. Pp. 213-231.

Recommended

-N. Rose. 2007. Beyond medicalisation. Lancet 369: 700-702.

-D. Fassin. 2008. The embodied past: From paranoid style to politics of memory in South Africa. Social Anthropology 16(3): 312-328.

- A. Petryna. 2009. Biological citizenship after Chernobyl. In: Anthropology and Public Health: Bridging Differences in Culture and Society, Second Edition.

- I. Hacking. 2000. Madness: Biological or constructed? In: The Social Construction of What? Pp. 100-124.

Nov 11: Veteran’s Day – No Class

Week Thirteen

Nov 16: Drinking – Falling in Love

Book: Knapp, Prologue, Ch 1-5

Reading:

-D. Lende. 2005. Wanting and drug use: A biocultural analysis of addiction.  Ethos 33(1): 100-124.

-N. Dow Schull. 2005. Digital gambling: The coincidence of desire and design. The Annals of the American Academy of Political and Social Science 597(1): 65-81.

Recommended

-H. Kincaid & J. Sullivan. 2010. Medical models of addiction. In: What Is Addiction? Pp. 353-376.

Nov 18: Film: Dope Sick Love

Week Fourteen

Nov 23: Drinking – Complications

Book: Knapp, Ch 6 – 10

Reading:

- A. Garcia. 2008. The elegiac addict. Cultural Anthropology 23(4): 718-746.

Recommended

- D. Lende. 2007. Evolution and modern behavioral problems. In: Evolutionary Medicine and Health: New Perspectives, W. Trevathan, E.O. Smith & J. McKenna, eds. Pp. 277-290.

Nov 25: Thanksgiving – No Class

Week Fifteen

Nov 30: Drinking – Addiction and Recovery

Book: Knapp 11-16

Reading:

- D. Lende. In prep. Addiction and the brain: Turning neuroscience into neuroanthropology.

Due: Final Revision of PLoS Post (absolute deadline – if possible, complete earlier)

Recommended

- NIDA Principles of Drug Treatment. Pp. v – 60

- H. Castañeda et al. 2008. Enabling and sustaining the activities of lay health influencers: Lessons from a community-based tobacco cessation intervention study. Health Promotion Practice 11(4): 483-492.

Dec 2: Poster Session

Week Sixteen

Dec 9: Final Paper due by 5:00PM

Diane was diagnosed with HIV at eight months old. She was infected through her mother, who was not aware that Diane’s father, her husband at the time, had HIV. He left before Diane’s mother found out that she had HIV and that she had passed it on to her newborn daughter.

Infected with HIV for her entire life, Diane “acts like she doesn’t have it” and “tries to go on with her life” even though she thinks about it everyday.

HIV has had a huge impact throughout Diane’s (a pseudonym) twenty-one years of life. One summer she was given just months to live, and her family, doubtful she would live until December, celebrated Christmas in July. She has survived several health scares, and although her health is currently not great, it is improving as her new medication begins to bring her viral load under control.

The Challenges of Being HIV-Positive… and a Woman

HIV-positive women cope with their disease in ways that are strikingly different from HIV-positive men. Women’s roles as caregivers, mothers, wives, and daughters make their experiences with HIV unique. These roles shape how much they are willing to deal with the disease on a daily basis as many women put the needs of their children and families before their own. Furthermore, their identities as caregivers may conflict with their identities as recipients of care that their HIV status necessitates. Consequently, these women, many of whom are in difficult socioeconomic situations, may not seek the support they need.

To help these women, last year a group of students helped to establish a much-needed HIV/AIDS women’s support group in our Midwestern city (see their post, Just A Place to Talk: Women & HIV/AIDS). It was a success initially. However, the student who helped facilitate the support group moved away this summer, and the support group lost its impetus.

This year our community-based research project explored why women stopped attending the support group, women’s interest in participating in a new support group, and how to develop a support network that addresses the many needs of HIV-positive women. The two most important lessons we learned this semester include the importance of emotional support and the value of resources, such as transportation and childcare, that enable these women to care for themselves and their families while living with HIV.

Seeking Solidarity and Support

Several women expressed a desire to learn from others who are willing to share their experiences with HIV. They think that sharing their stories with other HIV-positive women will lessen feelings of isolation and better equip these women to handle the burdens of the illness. As Joyce, who has been HIV-positive for twelve years, reported, she is interested in the group because she “wants to feel supported.”

Four of the eleven women we interviewed had attended at least one of last year’s support group meetings, but they stopped going to the meetings because of consistently low attendance.

Shannon, who was diagnosed with HIV seventeen years ago, believes “getting women to come out and talk about their condition” is the most difficult part of organizing a support group; however, she says she would be more willing to come to the meetings “if she knew that there were going to be people there each week.”

Margaret, who has been HIV-positive for twenty years, attended several of the women’s support group meetings last year. During the interview, she seemed a little frustrated that some of the women stopped showing up, but she understands the obstacles women face in getting to weekly support group meetings: “I know people have things to do and things come up, but people attending is the biggest thing. It usually starts out pretty good but then just dies off.”

Increasing Attendance

So how should we go about addressing the attendance issue? How do we get women to come to the support group meetings each week? Women said that they would be more likely to return to the support group each week if they were learning new things, feeling supported, and helping other women deal with the challenges of HIV/AIDS.

“Fellowship, friendships, and a chance to learn how the disease is for others” are the major things that Adrienne, who has attended three different support groups, would like out of a support group.

Sue is looking for a group of “nice women who are willing to come, be supportive, and respect someone else’s privacy.” Sue also said she would like the support group “to make her feel better about her illness, like she is not the only one with HIV.”

Many HIV-positive women, like Sue, feel alone and uncomfortable talking about their illness. Most do not even tell their family or close friends about their status. One woman disclosed that she has gone a year without interacting with another HIV-positive woman. Consequently, it can be very difficult for women to handle all of the challenges they face, especially if they feel isolated and depressed as a result of their illness.

A support group, however, enables women to share their stories and to understand that they are not alone in their struggle. They can cultivate genuine friendships and establish an intimate support network that can help them overcome obstacles associated with HIV.

Kara, who contracted HIV from her then drug-abusing husband nearly twenty years ago, has definitely felt her fair share of isolation. She would like to get involved in a support group in order to share her story and help other women deal with HIV. Kara told us, “I would come to the meetings each week knowing that I could help someone.”

Some women, however, are either not comfortable sharing their HIV status with others or do not want to discuss their illness because “they are feeling pretty good.” Margaret, who has been blind since suffering from severe complications of HIV nearly fifteen years ago, has been undetectable for ten years and says, “Now that the virus is undetectable, it is not really a topic of discussion.”

A student involved in last year’s support group talked with us about encouraging women like Margaret to come to support group meetings and share their stories of hope with women who are struggling with a recent diagnosis, a health scare, or feelings of loneliness and despair. It is important that these women know how much they can impact the lives of other HIV-positive women who are seeking a safe space to voice their concerns about HIV and to find encouragement and solace in the experiences of others.

A Support Network

After talking to eleven HIV-positive women, we realized they have a variety of emotional and financial needs. Many HIV-positive women are looking for more than just a support group. They need a support network.

A support network will provide women with the resources needed to live their daily lives as well as to fight the disease. In addition to friendships with other HIV-positive women, this multi-faceted support system will provide women with everything from basic necessities, such as toiletries and food, to childcare and reliable transportation to healthcare appointments.

Many HIV-positive women are mothers and need help with childcare so they can visit the doctor or participate in a support group. Some women mentioned that more resources should be tailored to the specific needs of HIV-positive single mothers.

Adrienne, who was diagnosed with HIV eighteen years ago, suggested that support for HIV-positive women should be more comprehensive and aim to “help the family as a whole” as HIV affects not just individuals but entire families.

“I could use support in the form of childcare and money for utilities but any type of support is welcome. Anything can help,” says Sue, a young mother of three children under the age of seven who has been HIV-positive for four years.

Many women are unemployed and must get by on a fixed monthly income. They also do not have access to reliable transportation. These problems are barriers to the support they might receive if they had the money, time, and resources to seek it out. In consideration of the obstacles these women face, we decided to explore their needs and determine how best to support local HIV-positive women.

With a support network in place, these women could better confront their disease and make it through each day. Beyond the basic needs of food, transportation to doctor’s appointments, and occasional childcare, these women also desire emotional support. Some keep a positive attitude like Adrienne, who insists that “the disease won’t beat me”; however, many feel depressed and isolated from others.

Most women claim they are not treated differently because of their HIV status simply because they do not tell anyone about their disease. These women are especially in need of a support group to minimize mental health risks associated with hiding a significant part of their lives from others. Improving the support network for these women in terms of monetary and emotional needs decreases their risks of mental illnesses, such as depression, that stem from their HIV-positive status.

Women, particularly young women like Diane and Sue, are a demographic not often associated with HIV. As a result, support services often do not directly address their needs or provide the appropriate type of care. Some are ashamed of their diagnosis, some are fearful of what others will think if they find out about their HIV status, and others are concerned about opportunistic infections and other complications of HIV.

Whatever their concerns may be, all HIV-positive women are in need of additional resources and improved support networks to face their illness and its many challenges. Women, burdened with their responsibilities as daughters, wives, and mothers, now more than ever, need strong support networks behind them.

Further Reading

World AIDS Day Official Website

AVERT: Averting HIV and AIDS

AIDS.gov: United States Department of Health and Human Services

Pittiglio, L. and E. Hough (2009). Coping with HIV: Perspectives of Mothers. Journal of the Association of Nurses in AIDS Care 20(3):184-92.

Bova, C. et al. (2008) Improving Women’s Adjustment to HIV Infection: Results of the Positive Life Skills Workshop Project. Journal of the Association of Nurses in AIDS Care 19(1):58-65.

“Why do I pregame?” The third year American History student repeated our question with a bit of sarcasm in his voice. He put down his textbook and then delivered his jovial response:

“Why wouldn’t I pregame?! It makes everything better- bars, parties, dances, football, class, work…”

This is the pregaming mentality expressed by a current undergrad at our mid-Western university. This mentality can be summarized: if you have to go to something, why not be buzzed when you do it?

Across the country, on any given weekend night, college students are often consuming four or five, sometimes even 10 drinks, before they even make it out of their dorm room for a night of partying, the dorm dance, or even the latest sports event.

They consume what many medical professionals construe as dangerous, sometimes lethal, amounts of alcohol in a short period of time. Then students often find themselves passing out, throwing up and even being taken to the hospital. And that’s before they even make it to the party.

From an outsider’s point of view, this may not sound like a lot of fun. For college students, pregaming is often the best part of the night. Our question as student researchers was, Why?

Our Research

Due to the recent emergence of pregaming, little is known about the mentality behind it. Working with the university group in charge of helping to prevent and treat alcohol abuse, we aimed to understand the social and cultural bases for high-risk drinking and pregaming. Previous student research on pregaming focused on gender differences, and can be found in the post “College Drinking: Battle of the Sexes?”

The statistics were already clear for the university office in charge of alcohol education and prevention – almost 80% of students who have gotten in trouble for alcohol-related events were pregaming on the night of the incident. Counselors there feared that the high-risk drinking habit of pregaming has become synonymous with students social lives.

Our project aimed at both understanding students’ general attitude towards pregaming as well as why students stop drinking on a given night. These questions could offer insight and clues to effective handling of the problem of pregaming by students and the university alike.

Throughout the Fall 2009 semester, we surveyed over 400 undergraduate students along with conducting student and counselor interviews. The surveys included nine questions regarding students’ drinking and pregaming habits. Ten student interviews of females and males were conducted to focus on attitudes toward pregaming. We also drew on our own insights and experiences as undergraduate students.

A Social Need

The main theme emerging from our research is the intense social aspect of pregaming. We were surprised to find out that many students actually enjoy the pregame over the party itself, simply because they enjoy being with a smaller group of friends.

“Pregames are usually a fun part of the night because you’re just with a few close friends before you go out and meet up with a lot more people and can’t chat and laugh with your close friends as much,” said one student.

Another student talked about how pregaming was a good way to organize your friends before going out. By getting together a group of people before the party, you’re not left with the possibility of going out to party alone.

Additionally, we found that many students pregame to lower their inhibitions, making them more fun, outgoing and less awkward when they’re at a party. Whereas they may feel comfortable showing up to a pregame sober, they are very uncomfortable with the idea of showing up to a party sober.

As several students put it, pregaming “gets rid of potential awkwardness at the beginning of parties.” It gives you a “confidence boost” and makes you “more loose and able to socialize”. As described in previous student research Why Do They Do It? Portrayals of Alcohol on Facebook and MySpace, drinking is a way for students to “portray themselves as social, attractive, and popular.”

In general, students did not feel any need to “pregame” the pregame. This suggests that students do not have the same reservations about being at a pregame sober as they do about being at a party sober. The people they pregame with are oftentimes the same people they study with, eat with and simply hang out with on a regular basis. They are used to being sober with these people and therefore don’t worry about having to carry on what might other times be awkward conservations with them.

However, when students make it to a party, bar, or dance, they are surrounded by students they are not used to interacting with. They may feel self-conscious and uncomfortable talking to people they don’t know, and thus use alcohol as a “social lubricant,” getting them drunk before the party to avoid these potential awkward encounters.

Our surveys also showed that many students admit to pregaming so hard that they never make it to the intended event or “blacking out before the party even starts”. Every student interviewed remembered instances when they or one of their close friends did not make it to the main event they were pregaming for. When students pregame they are oftentimes more concerned about the pregame itself than the event they’re going to afterwards. “Pregaming is the party,” one student noted while laughing nonchalantly.

Drinking to Dance

One particular concern counselors have is the pregaming that goes on before dormitory dances. Throughout the school year different resident halls host both informal and formal dances. These events are intended to be a fun outing for the residents of each hall.

Unfortunately, in recent years these dances have turned into excuses for massive amounts of pregaming. Because alcohol is not typically served at the dances many students feel an added pressure to get drunk prior to attending the dance itself. Moreover, many students, as mentioned earlier, feel awkward and uncomfortable at these events unless they have already been drinking.

To overcome these problems, students will pregame, consuming up to 8-10 drinks in a matter of an hour or two before going to the dance. This inevitably leaves many students vomiting in bathrooms, passing out on the dance floor and sometimes even being rushed to the hospital because of alcohol poisoning. During a recent dorm dance, between 20-23 students were either personally walked home or ejected from the dance for alcohol related incidents.

Why Should I Stop?

Determining why students stop drinking on a given night gave us insight into why students are drinking in the first place. By finding out what students are trying to avoid when they stop drinking, we have gotten better insight on what to educate students on.

Students reported two top reasons for why they stop drinking. The first is because they “reach [their] limit” which involves throwing up, passing out or being hung over the next day. The second was that their friends stopped drinking. Students stop when their friends stop because they didn’t want to look bad in front of their friends or their friends told them to stop. Pregaming would accelerate the occurrence of both reaching one’s limit and of friends drinking ending.

Since “limits” and social reaction are the two most important reasons students quit drinking, these are two areas that should be focused on when creating alcohol education systems.

While a few students admit they “don’t see the appeal of pregaming,” the majority of students do not agree. Counselors must seek to better understand why students want to “get the juices flowing” and “get drunk as early as possible,” before they will be able to help students avoid the penalties, embarrassing events and hospital visits that often accompany this high-risk action.

Now What?

Unfortunately, many students do not always realize the serious health risks that come with pregaming. Surveys indicate that students are more concerned about getting caught pregaming than they are about any potential health risks.

Counselors fear that the “work hard, play hard” mentality of many students will not disappear after graduation. Counselors worry that upon entering the work force, graduates will continue to turn to alcohol to cope with stress, simply because that is what they have trained themselves to do.

So what do we do about pregaming and the risks it brings? The current modes of educating students about the risks associated with pregaming are very limited. Pregaming is a relatively new phenomenon and many universities are just beginning to assess ways to combat it. Current alcohol education programs focus on abstinence from drinking, which has not been shown as affective.

Since research shows that students do not worry about the health risks associated with pregaming, it would be prudent to focus future education initiatives on the health effects of such practices. College students respond to facts and information. They are past the age of being told that if something is bad they shouldn’t do it. This might help explain why programs that ask students to abstain from drinking because it’s unhealthy do not seem to be working. However, if programs focused on laying out the proven effects of alcohol consumption on an adolescent body, students may respond more favorably.

Based on our research, we believe that a particular focus should be placed on dances, which attract the highest levels of pregaming and its negative consequences. It is believed by group members that dormitory regulations currently in place before and during school sponsored dances need to be rethought. Rules regarding time limits on social gatherings that were originally put into place to keep students safe are becoming more and more detrimental to students’ health.

In the end, counselors’ best hope for cutting down student pregaming and the risks it entails is to address the social issue. Provide options on other social activities for students to take part in. Use students’ social networks to their advantage; use friends to get friends to cut down on their heavy pregaming habits. We know that if our friends told us we were drinking too much, we would most likely stop.

-//-

Acknowledgements: A special thanks to the director of our local university alcohol education and prevention program for insight and support.

You can access the entire draft here at the American Psychiatric Association DSM-5 Development Website. There the APA writes about the comment policy:

The draft disorders and disorder criteria that have been proposed by the DSM-5 Work Groups can be found on these pages. Use the links below to read about proposed changes to the disorders that interest you. Please note that the proposed criteria listed here are not final. These are initial drafts of the recommendations that have been made to date by the DSM-5 Work Groups. Viewers will be able to submit comments until April 20, 2010. After that time, this site will be available for viewing only.

It is interesting to note that the APA included a press release announcing that the DSM-5 Development Process Includes Emphasis on Gender and Cultural Sensitivity.

Actual proposed changes are set up in an interesting way. The opening tab is the proposed revision, but there is also are rationale, severity, and DSM-IV tabs. So it does provide more information than one might think.

So, as one major example, Major Depressive Disorder, Recurrent, has an extensive draft proposal for the DSM-5. Here the rationale isn’t that great, since it largely focuses on single episodes of depression. On the severity side, it’s clear what the APA group is thinking about in terms of differential ratings. And it’s easy to compare the DSM-5 with the DSM-IV criteria.

Vaughan Bell at Mind Hacks includes some extensive commentary, and a wealth of links, on the DSM-5 Draft in the piece The Draft of the New ‘Psychiatric Bible’ Is Published. He opens by saying:

It’s a masterpiece of compromise – intended to be largely backwardly compatible, so most psychiatrists could just get on diagnosing the few major mental illnesses that all clinicians recognise in the same way they always did, with some extra features if you’re an advanced user.

One of the most striking extra features is the addition of dimensions. These are essentially mini questionnaire-like ratings that allow the extent of a condition to be numerically rated, rather than just relying on a ‘you have it or you do not’ categorical diagnosis.

John Grohol, writing over at Psych Central, also provides an initial overview of the main changes in the DSM-V and then provides a review that features the good, the bad and the ugly.

If you’re looking for just the critical, the Psychiatric Times has a piece Opening Pandora’s Box: The 19 Worst Suggestions For DSM-5. Dr. Allen Frances, who chaired the DSM-IV Task Force, identifies two areas that are quite worrisome (and predictable) for a critical medical anthropologist:

(1) Dramatically higher rates of mental disorder, including “millions of newly misidentified false positive ‘patients’ [and] massive overtreatment with medications that are unnecessary, expensive, and often quite harmful”

(2) Unforeseen consequences, where DSM5 options often have an “insensitivity to possible misuse in forensic settings. Work Group members cannot be expected to anticipate the many ways lawyers will try to twist their good intentions.”

You can explore the legal aspects more over at In the News.

For specific diagnoses, Dr. Petra has particularly good coverage on the proposed changes in sexual disorders. Liz Spikol looks at the diagnosis of childhood bipolar disorder with a critical eye.

For more reading, Furious Seasons has some good initial thoughts on the DSM-5. Additional coverage can be found at the NY Times and New Scientist.

Ronald Wintrob, chair of the World Psychiatric Association–Transcultural Psychiatry Section, writes the Introduction to Cross-Cultural Psychiatry for this special report. He notes how migration has increased over the past 20 years, and that 12.86% of the US population are immigrants. Psychiatrists have put increasing effort into engaging these populations.

One of the most practical applications of cultural psychiatry to clinical practice in all fields of medicine is the open-ended questioning of patients and their families about their personal and family background characteristics. This includes identifying features of race, ethnicity, religion, and socioeconomic class, relevant immigration history, experiences of acculturative stress, and personal and family aspirations. A discussion of these background characteristics can lead naturally to the clinician’s exploration of the presenting clinical symptoms and history. Knowledge of the patient’s background will increase rapport with patients and families and aid the process of collecting a more reliable history. In addition, it will improve the likelihood of treatment adherence. This process has been described as “cultural case formulation.”

Three main articles comprise the special issue:

Religion, Spirituality, and Mental Health by Simon Dein, senior lecturer of anthropology and medicine at University College London. This piece provides an in-depth examination of what is currently known about the relationships between religion and mental health, and also includes a handy set of four check points that summarize the main themes of the article.

Cultural Considerations in Child and Adolescent Psychiatry, by Toby Measham, Jaswant Guzder, Cécile Rousseau, and Lucie Nadeau, all in the department of psychiatry at McGill, which presents a series of guidelines and suggestions for how to handle cross-cultural issues in practice with children and adolescents

Cultural and Ethnic Issues in Psychopharmacology, by Keh-Ming Lin, professor emeritus in psychiatry at UCLA. This piece goes from the placebo effect to genetic variation, and argues that “cultural and ethnic influences… should be regarded as central in determining the success of treatment interventions.”

Under the whole category of cross-cultural psychiatry at Psychiatric Times, you can also find other articles, including this one by J. David Kinzie on A Model for Treating Refugees Traumatized by Violence.

Link to the Introduction to the Special Report on Cross-Cultural Psychiatry.

As they write about their initiative:

Do unauthorized im/migrants have a right to health? To medical care? To publicly funded care? In this blog, medical anthropologists host a lively conversation among scholars, activists, policymakers and others on the complex and contentious issue of unauthorized migration and health. We approach the issue comparatively, with attention to power, cultural context, and historical depth. Through empirically grounded, critical dialogue, we aim to rethink current debates and inform policy about unauthorized migration and the right to health care.

Recent posts include What do Haitian Earthquake Survivors and the Super Bowl Have in Common?, which addresses the mounting controversy over stopping survivors of the Haitian earthquake from entering Florida to receive urgently needed health care, and Chutes and Ladders: Comprehensive Immigration Reform and Health Care Access for Undocumented Workers, which provides a long-term view of immigration and health using the lens of Mexican illegal immigrants to Idaho.

The Access Denied team also puts together regular News Round Ups, with the most recent one delving into the serious problems surrounding deaths among immigrants held in custody by US Immigration and Customs Enforcement.

The overall site delivers a complete package, including an extensive working bibliography, a good list of web resources on immigration and health, and most importantly Access Denied’s recommendations for Action Steps you can take to address the problems surrounding immigration and health.

Access Denied was founded by a great group of people, including Sarah Willen, a friend of mine from graduate school and now assistant professor at Southern Methodist University, and Heide Castañeda, an assistant professor at the University of South Florida, whom I had the pleasure of meeting on my recent trip there.

Other founding members include Nolan Kline, a graduate student at the University of South Florida, and Jessica Mulligan, a post-doc at the Holleran Center for Community Action and Public Policy. You can see the entire team here, including profiles of the founders and guest contributors.

Those guest contributors have included some outstanding senior people, including Didier Fassin, who just joined the prestigious Institute for Advanced Study at Princeton, on Illegal Immigrants as the Last Frontier of Welfare, and Peter Guarnaccia, Professor in Human Ecology at Rutgers, on Health Care Reform Is Intimately Linked to Immigration Reform.

For even more, go check out the new medical anthropology blog Access Denied.

graphic by Alex Trochut, NYTimes

The ethnographic record is full of conditions that didn’t make it into the most recent edition of the DSM — amok, nervios, koro, zar — you can check out Wikipedia or some other source on ‘culture bound syndromes,’ such as Introduction to Culture-Bound Syndromes in Psychiatric Times, to get a fuller discussion of some of these conditions. The Psychiatric Times piece suggests that there are at least 200 culture-bound syndromes.

One thing I really liked about the New York Times Magazine article, however (and by extension, Watters’ book, I suspect), is that the discussion of ‘culture-bound syndromes’ usually tends to treat other people’s syndromes as ‘culture-bound,’ Western psychological illnesses as not ‘culture-bound.’ Watters’ work points out that Western mental illness is both itself culture-bound and that persuading people to believe in Western-style mental illness can affect the way that psychic disorders manifest.

In fact, even Western history is littered with examples of truly odd and intriguing psychic illnesses that we seem to be vulnerable to for short periods of time. If you’re starved for more examples of culturally induced psychological conditions that include both Western and non-Western versions, you could check out Outbreak: The Encyclopedia of Extraordinary Social Behaviour, also discussed at Mind Hacks. Sounds like a brilliant read, with material like the following cited by Vaughan:

The Fortean Times article has some great excerpts covering an outbreak of feinting in a marching band in 1973 Alabama (a classic case of mass hysteria), an outbreak of cat-like meowing in India in 2004, the 1958 hula-hoop craze, a goblin scare that affect Zimbabwe in 2002, a ‘culture bound syndrome’ with the unusual name of the jumping Frenchmen of Maine from the 18th and 19th centuries, various outbreaks of fears about chemtrails, a giant earthworm hoax that panicked a Texas town in 1993, and a version of Orson Well’s War of the Worlds that caused widespread rioting in Ecuador in 1949.

But I digress simply because the examples themselves are so fascinating…

To return to the New York Times Magazine piece, Watters discusses how a group of psychological anthropologists and cross-cultural psychologists have argued that, just as humans are psychologically and socially diverse, they are diverse, too, when it comes to psychic ailments:

Swimming against the biomedical currents of the time, they have argued that mental illnesses are not discrete entities like the polio virus with their own natural histories. These researchers have amassed an impressive body of evidence suggesting that mental illnesses have never been the same the world over (either in prevalence or in form) but are inevitably sparked and shaped by the ethos of particular times and places.

Between the lines, the article suggests two slightly different, competing explanations for this diversity in psychological illness. On the one hand, the variety might arise because the language of somatization of distress varies from place to place. As one source for Watters’ article argues:

“We might think of the culture as possessing a ‘symptom repertoire’ — a range of physical symptoms available to the unconscious mind for the physical expression of psychological conflict,” Edward Shorter, a medical historian at the University of Toronto, wrote in his book “Paralysis: The Rise and Fall of a ‘Hysterical’ Symptom.” “In some epochs, convulsions, the sudden inability to speak or terrible leg pain may loom prominently in the repertoire. In other epochs patients may draw chiefly upon such symptoms as abdominal pain, false estimates of body weight and enervating weakness as metaphors for conveying psychic stress.”

In Shorter’s explanation, symptoms are a kind of social communication of ‘psychological conflict,’ varying because different eras and areas offer different ‘symptom repertoires,’ different palettes in which to paint one’s distress. In this model, because the community or specialists respond to particular sorts of patient presentation, believing that certai symptoms are especially salient, the disorders quickly conform to the expectations of therapists, whether they wear white coats, tweed coats with arm patches, or ritual body paint.

While this is certainly possible, and maybe even probable in some cases, some psychological disorders seem to be less labile, less liable to renegotiation of the symptoms, although the symptoms do vary slightly across cultures or occur at different rates, have varied rates of recovery, or the like. Some disorders have neurological or neurochemical dynamics that are susceptible, at least in part, to treatment with drugs, so all symptoms may not be so culturally negotiable, although they might still vary in frequency, severity, and trajectory as I’ll discuss. That is, the ‘symptom repertoire’ explanation — which I concede likely explains some of the variation, but not all — demands that psychic illness be a kind of unconscious performance of internal, psychic conflict. The assumption seems to be that universal psychic dilemma — conflict — gets expressed in locally variable argot — symptom.

The second explanation which I find more compelling is implicit in the article, and not fully developed. A more holistic model of variation in psychological illness would concede that, in some cases, symptoms are very malleable, and some symptoms of a disorder may be susceptible to this type of modification-by-expectation, but there might be more intransigent organic dimensions of disorders that still might vary culturally, but not due only to therapists’ expectation. The domain of the ‘cultural’ might be broader and less inherently conscious than just ‘beliefs.’

The case of anorexia nervosa in Hong Kong

Let’s take the case of anorexia nervosa in Hong Kong that Watters discusses. According to Watters, Dr. Sing Lee documented occurrences of a rare form of anorexia in Hong Kong throughout the 1980s and 1990s. Lee’s patients ‘did not intentionally diet nor did they express a fear of becoming fat,’ instead complaining that they felt ‘bloated.’ Then in 1994, a very public case of a girl who had starved herself hit the press, and Dr. Lee noticed a shift in anorexia: the number of cases climbed, and the sufferers began to diet and express fear of becoming fat, just like the American version of the disorder: ‘As the general public and the region’s mental-health professionals came to understand the American diagnosis of anorexia, the presentation of the illness in Lee’s patient population appeared to transform into the more virulent American standard.’

Lee explains how generalized psychological disorder leads to a specific eating disorder: ‘When there is a cultural atmosphere in which professionals, the media, schools, doctors, psychologists all recognize and endorse and talk about and publicize eating disorders, then people can be triggered to consciously or unconsciously pick eating-disorder pathology as a way to express that conflict.’

But is that really all that happened, people talking about anorexia? Was it simply a matter of mental-health professionals inadvertently causing the more benign strain of anorexia in Hong Kong to mutate into the American version? The increase in fat phobia among anorexic sufferers did not occur in a vacuum, I would argue, affected only by mental health specialists. I suspect other Western influences likely also contributed to the shift, including ‘diet’ discourse, maybe even changes in actual diet, media imagery of idealized bodies, and the fitness industry. And what about shifts within this population in anxiety levels, sexuality-related expectations, fashion, socializing, male-female relations, and other more indigenous, though certainly not isolated dynamics? And was there an incursion of the material culture of Western dieting, such as diet drinks, calorie counting techniques or food labelling, or even high-fat foods to both affect body type and to provide a medium in which to express control over oneself. Just as the changing prevalence of anorexia nervosa in the West can’t simply be chalked up to a single cause such as patients’ suggestibility, I doubt we could do the same in Hong Kong. Sure, the anorexia outbreak may be ignited by ‘psychic conflict,’ but why does it take this specific form, and why does the form change in prevalence?

That is, the simple story that therapists gave their patients anorexia is possible, but there are other potential candidate explanations, and we’re quite likely to have an accumulation of cultural shifts that helps to explain the change in Hong Kong. After all, not every Western disorder grows at the same rate simply because therapists talk about them; they intersect with local anxieties, changing lifestyles, even physiological traits.

Western ‘culture’ is not just a set of ideas but a whole constellation of ideas, concepts, images, practices, customs, material culture, technology, and other everyday factors that feed into these disorders, even when they are ‘expressions of of psychological conflict.’ Certainly in terms of global diet and bodily culture, Western ideas are not the only factors affecting global change: technological, commercial, economic, agronomical, demographic, educational, and even mechanical (in terms of access to transport) changes are also influencing how bodies are changing internationally. We shouldn’t be too surprised that disorder, hypervigilant eating becomes more prevalent when food ways are in such a state of upheaval, body images are raining down on these populations, activity patterns are shifting, and so many of the new choices are unhealthy, fattening, and alien.

Without doubt, Western ideas about mental illness are directly affecting expectations of psychic distress around the world; see, for example, Vaughan at Mind Hacks discussing Did Antidepressants Depress Japan?. Here Vaughan highlights another force, one touched on by Watters but not explored; pure mercenary impulses, as drug companies try to persuade new markets that the individuals ‘need’ their products, suffering as they do from disorders of which they were previously unaware. Here, the idea that it’s just the ‘beliefs’ about illness held by therapists and authorities obscures the naked greed that goes into public relations campaigns designed to produced disorder.

My argument is not so much that Watters is wrong, as that culture is not just in the ideas people have about disease; these changes in mental illness are also provoked by the social, technological, and material world, for example, how the export of Western-style education affects childhood elsewhere (and thus illuminates ‘disorders’). When Watters writes the following, I whole-heartedly agree:

In the end, what cross-cultural psychiatrists and anthropologists have to tell us is that all mental illnesses, including depression, P.T.S.D. and even schizophrenia, can be every bit as influenced by cultural beliefs and expectations today as hysterical-leg paralysis or the vapors or zar or any other mental illness ever experienced in the history of human madness. This does not mean that these illnesses and the pain associated with them are not real, or that sufferers deliberately shape their symptoms to fit a certain cultural niche. It means that a mental illness is an illness of the mind and cannot be understood without understanding the ideas, habits and predispositions — the idiosyncratic cultural trappings — of the mind that is its host.

Although I’m a little uncomfortable with the word ‘mind’ in the last sentence, I especially like the end of the passage. Yes, it’s true, you can’t understand a mental illness without understanding a bit about the… well, okay, ‘mind’ of the person suffering. It’s just that it’s not that narrow: you have to understand a bit about the developmental influences on their brain, about the social network that supports or stigmatizes them, the behavioural reserves for unusual behaviour or thoughts… It’s not just about the conscious stories and understandings, but also about the harder-to-pin-down social, behavioural, and developmental factors that affect disease expression.

Watters actually provides a great example of these non-belief cultural factors when he discusses one of the more interesting dilemmas in cross-cultural psychiatry:

The research showed that patients outside the United States and Europe had significantly lower relapse rates — as much as two-thirds lower in one follow-up study. These findings have been widely discussed and debated in part because of their obvious incongruity: the regions of the world with the most resources to devote to the illness — the best technology, the cutting-edge medicines and the best-financed academic and private-research institutions — had the most troubled and socially marginalized patients.

Watters seeks to explain this unexpected gap in treatment by discussing the work of anthropologist Juli McGruder (University of Puget Sound) on families of schizophrenics in Zanzibar. In Zanzibar, schizophrenics are believed to be suffering from intermittent bouts of spirit possession. To cut to the chase, this belief affects those around them, especially family members, which affects how they treat the individual with the condition: ‘With schizophrenia… symptoms are inevitably entangled in a person’s complex interactions with those around him or her. In fact, researchers have long documented how certain emotional reactions from family members correlate with higher relapse rates for people who have a diagnosis of schizophrenia.’ It turns out that interaction patterns with a person possessed by spirits are actually healthier than those of family members in the West who believe the individual has a ‘mental illness.’ In fact, with US families, the more they try to ‘care’ for the schizophrenic family member, the more they fall into an unproductive interaction pattern with the individual with the illness. The issue is not just the belief, but the emotional quality of family interaction with a suffering individual; treat them one way, and it’s not just that you believe they’re different — the individual actually becomes different.

The discussion of trauma and trauma recovery is quite short, but Watters does highlight nicely some of the problems of exporting Western-style treatment to deal with trauma that we expect others to feel.

Behind the promotion of Western ideas of mental health and healing lie a variety of cultural assumptions about human nature. Westerners share, for instance, evolving beliefs about what type of life event is likely to make one psychologically traumatized, and we agree that venting emotions by talking is more healthy than stoic silence. We’ve come to agree that the human mind is rather fragile and that it is best to consider many emotional experiences and mental states as illnesses that require professional intervention. (The National Institute of Mental Health reports that a quarter of Americans have diagnosable mental illnesses each year.) The ideas we export often have at their heart a particularly American brand of hyperintrospection — a penchant for “psychologizing” daily existence.

Even dealing with Australians, I find that this is a huge difference, that the need for hyperintrospection, for obsessive re-tracing of distressing events or conflict, the need for a ‘talking out’ to resolution of issues is simply not shared. And Australian are widely considered to be some of the most culturally similar people to Americans. Certainly, the gap I felt in Brazil was even greater.

I found the conclusion to the article even more surprising, a kind of reverse-diagosis of Americans to suggest that the exportation of American psychiatric health may not be in the interest of the globe:

If our rising need for mental-health services does indeed spring from a breakdown of meaning, our insistence that the rest of the world think like us may be all the more problematic. Offering the latest Western mental-health theories, treatments and categories in an attempt to ameliorate the psychological stress sparked by modernization and globalization is not a solution; it may be part of the problem. When we undermine local conceptions of the self and modes of healing, we may be speeding along the disorienting changes that are at the very heart of much of the world’s mental distress.

I’ll just leave it at this, as I don’t have anything else to add to the conclusion. I heartily recommend the original article, and was genuinely surprised to read something I felt was both engaging (well written) and yet still very thorough (well thought).

The role of race in human genetics and biomedical research is among the most contested issues in science. Much debate centers on the relative importance of genetic versus sociocultural factors in explaining racial inequalities in health. However, few studies integrate genetic and sociocultural data to test competing explanations directly.

Note how that fits so well into the points just made in Nature/Nurture: Slash to the Rescue. But Gravlee, Non and Mulligan don’t just say we need to overcome the nature vs. nurture dichotomy, they do research that bridges it and even better, test ideas on both sides: “We draw on ethnographic, epidemiologic, and genetic data collected in southeastern Puerto Rico to isolate two distinct variables for which race is often used as a proxy: genetic ancestry versus social classification.”

This type of collaborative research can be crucial to getting the data to answer complicated questions. Connie Mulligan and Lance Gravlee deserve credit for taking the time to discuss how to bring together their respective approaches before going out to do research. In this case, the data come down more on the nurture (or social) side. As they write:

Our preliminary results provide the most direct evidence to date that previously reported associations between genetic ancestry and health may be attributable to sociocultural factors related to race and racism, rather than to functional genetic differences between racially defined groups.

Before someone gets all hot and bothered, Lance has also shown how to bring nurture back to nature. In Gravlee’s recent paper, How Race Becomes Biology: Embodiment of Social Inequality (pdf), he gives us following: “Drawing on recent developments in neighboring disciplines, I present a model for explaining how racial inequality becomes embodied – literally – in the biological well-being of racialized groups and individuals. This model requires a shift in the way we articulate the critique of race as bad biology.”

In the PLoS paper, Lance, Amy and Connie are aiming squarely at the use of race in medicine, where it has become common in some circles to use racial classification as a proxy for genetics. Basically this research destroys the proxy notion, since social classification turns out to be a better predictor of blood pressure than genetic ancestry.

Yet the research also highlights that genetics does play a role, just not in the broad way we normally think (nature as cause). Specifically the data revealed an association between systolic blood pressure and a specific polymorphism, α2C adrenergic receptor deletion, only when social classification and socioeconomic status were included in the analysis.

This research also reveals social complexity. As the figure from the PLoS paper above indicates, there are interactions between racial classification, socioeconomic status, and systolic blood pressure in Puerto Rico. The basic conclusion is the opposite of what many of us might expect – those perceived as darker (negro) have higher blood pressure when in a higher social class. Conversely, those with lighter skin have higher blood pressure with lower SES. These results can be related to complex social dynamics. Darker colored individuals likely face more racial discrimination when in a higher SES because Puerto Rico is still a racially divided country, with wealth and status running lighter to darker. Here is the PLoS paper:

The pattern we observe is consistent with the hypothesis that social classification based on color entails differential exposure to social stressors related to blood pressure. In particular, there is ethnographic evidence that Puerto Ricans perceived as negro, as compared to trigueño or blanco, may encounter more frequent frustrating interactions in high-SES settings due to institutional and interpersonal discrimination.

Put in a broader sense, this paper points to the need to actively consider social inequality and discrimination as causes of health problem, something the “race as genetics” idea completely fails to do. Along with colleagues, Gravlee has made this point forcefully in a previous paper, Race and Ethnicity in Public Health Research: Models to Explain Health Disparities.

At the end of the PLoS paper Lance, Amy and Connie highlight an important direction for future research: “Although our measure of social classification improves on existing approaches, further research is needed to assess how well it approximates the ascription of color in everyday social interaction. Future research could build on our measurement approach by testing whether non-biological markers of social status (e.g., hair style, dress, speech) influence social classification.”

I’d also encourage Lance and his colleagues to look more closely at perceived discrimination, that this is also a crucial mediator of how race ends up driving biology. It’s not just consensus about racial classification, but how an individual person reacts to that. This point is made broadly by Robert Sampson when he discusses perceptions of disorder as an important force behind disparity. Building an ethnographically informed measure of subjective discrimination could add an important link in the pathway from social inequality to changes in blood pressure.

But this paper also challenged me. What is particularly good is that Lance builds on previous research that established how social classification according to “color” trumps actual skin pigmentation in establishing race and in impacting health. Now he and Connie have taken that a step further to get the data and test both biological and cultural ideas.

So this morning I am thinking more seriously how I could better examine the nature/nurture debate around addiction (quite similar in form to the race and health debate – biology does it; no, it’s inequality). How can studying sin become a closer look at how people get engaged in destructive behaviors, and which factors (working together, I’d say) are most important? Because right now the biologists are going to say, well it’s dopamine (or glutamate or whatever neurotransmitter is the flavor of the day) and the anthropologists are going to say, well it’s meaning. I’m still stuck at saying “holistic interactionism” (as Pinker would put it) rather than showing more concretely how the two come together and then relating both to genetics and to symbolism.

Lance Gravlee, Amy Non and Connie Mulligan have already taken that next concrete step. Kudos!

For more on Lance Gravlee’s work, please visit his website. For more on Connie Mulligan’s work, here’s her UF website.

For those looking for coverage of some of the paper’s highlights, you can check out the University of Florida’s press release, Socio-cultural, genetic data work together to reveal health disparities.

Gene Expression also provides a useful summary with Hypertension, Race, Class and Puerto Rico, including a comment by Lance clarifying a couple points.

And here’s the link for the PLoS full text of Genetic Ancestry, Social Classification, and Racial Inequalities in Blood Pressure in Southeastern Puerto Rico.

Imagine you are hungry. You have been hungry for weeks, with no end in sight due to a heavy drought that severely diminished your land’s production. Your gravely ill sister lives with you, as do her two young children, further straining your limited food supply. Then your neighbor dies. You do mourn, but you also feel relief – relief because you will be able to take your family to the funeral. There they will be able to eat.

This post examines food crises in Lesotho and the role funerals play in coping with these food shortages within a rural town and neighboring villages. In my senior thesis written on the costly funerals in Lesotho and the impact of HIV/AIDS on their practice, I found that the local Basotho people use funerals as a food coping mechanism. Lesotho often suffers from periods of drought that place a burden on food resources and force people to look for methods to supplement their daily food.

I will begin with a brief look at the factors behind the food shortages, followed by a description of funeral practices and how families are able to use them to for food coping. Lesotho is a small country in southern Africa. Through a quirk in British rule, it remained independent from South Africa and is now the only country to have its entire border completely surrounded by another country. The terrain is mountainous and has earned Lesotho the nickname of “the roof of Africa.” Less than eleven percent of the land is arable and farmers are at the peril of periodic droughts.

Lesotho also has one of the highest HIV/AIDS prevalence rates in the world, with some estimates as high as thirty-one percent of its over two million population carrying the virus (Brummer 2002). The high percentage stems from Lesotho’s history of labor migration to the gold and diamond mines of South Africa, where Basotho men would contract the disease and then bring it home to their families in Lesotho.

The attraction of mining employment to Basotho (from Lesotho) men comes partially from the lack of opportunities at home. Agriculture production has dropped in the past fifty years due to deterioration of the land through erosion, mono-cropping, and overgrazing, insecurities in the system of land tenure that inhibited farmers from securing their holdings, population pressure that increased exploitation of arable land, and environmental factors like hail, frost, and drought (Murray 1981). These factors, coupled with population growth, mean that the frequency and severity of food crises has increased in the last century.

The data for understanding the role funerals play as a food coping mechanism arises from thesis fieldwork of two six week periods spent in Lesotho in the summers of 2007 and 2008 while working with Touching Tiny Lives, an organization dedicated to monitoring and maintaining the health of children in rural Lesotho. The methods include interviews, both formal and informal, with Basotho people, and observations. The interviews focused on experiences relating to funerals, which included questions about the food served, reasons for attending, and overall cost.

The basics for a funeral in Lesotho are a coffin, a cow, and other food for visitors to eat. The coffin protects the body and is a sign of status. The cow is slaughtered with a knife and its entrails used in a ritual where the children have their heads shaved and covered with the innards, signifying their new status as orphans. The family cooks the meat of the animal to go on the table with the other food prepared for the funeral. Sometimes a cow is too expensive, so a family will use a goat instead. The only other food that is always at a funeral is papa, a starch made from maize meal and similar in consistency to thick mashed potatoes. Other typical food includes chakalaka (a cooked vegetable mixture) and fried cabbage.

Usually, people go to a funeral voluntarily, however according to the interviewees, some village chiefs require that everyone in the village go to a funeral. Many said that the reason for attending was to console the family of the deceased: “They are just going to console the person.” This fact points to the value of funerals in terms of social cohesion within a village. Helping fellow village members can reinforce relationships between families. The support is a two way street, with the family receiving emotional backing and the attendees getting food.

Food has major drawing power for funerals in Lesotho, as reflected in this quote: “Yes they just go to eat! Especially if the cow is slaughtered. The people call it, if they have slaughtered a cow, a bus, but if it is a goat then it is a taxi. If it is a bus they know that it is a lot of meat.” If the number of people attending varies based upon the amount of food, then you could assume that for many villagers outside of close friends and family, consoling is not the top priority.

However, none of my interviewees openly admitted going to a funeral for the food; only “they” (other people) would go to eat. This observation may only be due to translation issues (some interviews were conducted with a translator), but more likely comes from the desire to not appear needy. The interviewees would not want to admit that they go to funerals just so they can eat. Identifying others as the users of the slang terms “bus” and “taxi” distances interviewees even further, implying that they would not use the words themselves.

From working experiences with Touching Tiny Lives, the need for supplemental food is evident. One of the services Touching Tiny Lives performs is giving food to families who have children. An emphasis is placed on the need for the food to go to the children, but tracking the children’s weight shows that this is not always the case. At times the only meal local children obtain is the daily lunch at school. The scarce diet, coupled with illnesses, creates a major health crisis that is being fought by local clinics and organizations such as Touching Tiny Lives. If funerals do provide a way to feed the needy, then this research could be used by these organizations to feed people through reinforcing local customs rather than foreign models of food distribution.

A previous study completed by Mphale (2002) indicates that people in the lowlands use funerals as a food coping mechanism during a time of food crisis. The responses obtained through the interviews and observations suggest that funerals are also a coping mechanism in the highlands. The The frequency and duration of food crises seem to have increased as well, since the spread of HIV/AIDS has lowered the number of able workers. Many households are without a male head and little or no income. These factors contribute to food shortages and malnutrition. Food is usually not the sole motivating factor for attending the funeral, but at certain times the presence of a quality meal plays a prominent factor in the decision to travel to the site of the ceremony.

The food at funerals connects the impact of HIV/AIDS and the ongoing food crisis, with the high costs and associated rituals. While HIV/AIDS kills more people and creates more funerals, others are able to be nourished from the traditions of Lesotho. This balance between life and death hinges upon funerals. My research encourages a strange and unorthodox solution, where the dead help to feed the living. Funerals are an obvious target for aid, where food and money can directly impact an entire village. While this intervention would by no means solve every problem, it would help to ease the pain felt in the hearts and stomachs of those most directly impacted by HIV/AIDS.

Works Cited

Brummer, Daan (2002). Labor Migration and HIV/AIDS in Southern Africa. International Organization for Migration.

Murray, Colin (1981). Families Divided. Ravan Press: Johannesburg, South Africa, 1981.

Mphale M. (2002). HIV/AIDS and Food Insecurity in Lesotho. National University of Lesotho.

Paul Farmer is a doctor and an anthropologist, and spoke as part of NPR’s series This I Believe. Farmer co-founded Partners in Health, a non-profit organization dedicated to improving health care for the poor around the world. He helped develop DOTS (directly observed therapy), a way to provide care for HIV/AIDS that works in resource-poor settings, as well as community-based approaches to treating multi-drug resistant TB in developing countries.

As an anthropologist he has emphasized the importance of structural violence, the negative impact that systems of power can have on people through racism, gender inequality and political violence, with significant articles in both Current Anthropology and PLoS Medicine.

His most recent book is Pathologies of Power: Health, Human Rights, and the New War on the Poor. You can also read about his lifework in Tracy Kidder’s biography, Mountains beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World.

Hat-tip (and thanks) to Ryan Anderson over at Ethnografix and his anthropological list of inspiring people and work.

Link to full text of Paul Farmer’s This I Believe NPR recording.