Pandora’s Box

Front matter

Ethnography and the Comparison of Medical Beliefs

NA S a

ETHNOGRAPHY AND THE COMPARISON OF MEDICAL BELIEFS

Contents

List of Figures vii Acknowledgments x Preface xii Part I: Being ill Chapter 1. Pandora’s box 3 Chapter 2. Village illness and a panic 13 Chapter 3. Long suffering and injustice 45 Chapter 4. The introduction of a medical aid post 13 Part II: Recognizing and defining illness Chapter 5. The meaning of “leprosy” 95 Chapter 6. The right diagnosis 109 Chapter 7. Normality and values 127 Chapter 8. No simple definition 137 Part III: Responses to change Chapter 9. Bregbo, a healing center in Côte d'Ivoire 147 Chapter 10. Witchcraft or depression 161

Chapter 11. The impact of events 171

Part IV: Treatment

Preface

My Lewis Henry Morgan lectures were first given at the Department of Anthropology at the University of Rochester in 1979 and then expanded in the early 1980s with the intention of publishing them. However, they overflowed the original lectures, and I left them unpublished. Now, at the kind suggestion of the Morgan Lecture Series editor, Professor Robert Foster, I have returned to the expanded typescript that grew out of the original lectures and have shortened the text. I hope it is clearer as well. I have not tried to bring it right up to date, since the gap between medical anthropology then and now is too great. However, I trust the themes I looked at then will still be of interest.

First, some background: I came into medical anthropology from initial medical training and a few years’ experience of hospital practice in Britains National Health Service. Social anthropology had long attracted me. What was it like to be ill in a society with no access to the sort of medicine I had been trained in? The contrast lured me and seemed to be a question that medical anthropology should try to answer before it was too late. I owe the quotation in my first chapter from Sir Thomas Browne to Mervyn Susser and William Watson (1962). Browne (1977) so eloquently expressed the question: Has there been progress in medicine? With Lewis Henry Morgan's Ancient society ([1877] 1964) in mind, this seemed perhaps a fitting theme.

In global terms of human survival, life expectancy, and demographics, progress has been made; however, in Part I, “Being ill,” the first chapter raises some doubt about the specific role of medicine in that progress. In any case, medicine is concerned not just with life expectancy and xii

Preface demographics but also with the illnesses of individuals and providing them with care in their illness.

The other chapters of Part I describe what it was like to be ill in a Sepik village in New Guinea: first in 1968-1969 and then about fifteen years later. Rauit was the village in the West Sepik District (now called Sandaun Province) where I lived with my wife Ariane and our toddler son for two years. The people in Rauit and two other villages were identified as speakers of a distinct language called Gnau, derived from its word for no. I had medical supplies suitable for a village health post supplied by the public health service. I provided medical advice when the villagers asked for some, thus altering the situation, but I thought it would be wrong not to offer to help when I was able to. Care provided by nonkin or strangers raised various problems of trust and compliance; some of these problems are tackled in later chapters of this book. I aimed to observe and record as far as I could all the responses to illness that occurred in the village where we lived.

To observe and understand local experiences were the descriptive goals of my first period of fieldwork. What were the environmental and medical problems faced in that particular setting, and what did locals do about them? The collection of data came before any particular explanatory theories. At the time, few studies were devoted to medical anthropology, either ethnographically or in anthropological theory. In chapter 2, I try to describe examples from the range of illness and responses to them as seen by the outside observer, bearing in mind that it is easy to neglect common minor ailments in favor of paying attention only to illnesses that demand more serious and dramatic responses. In chapter 3, I focus on the experience of suffering a long illness and on understanding the subjective experience of isolation, dependency, and rejection, of being unable to take part in ordinary activities and social life. But do others always recognize an obligation to help? Blame for illness and the justice or injustice of suffering are issues that raise questions.

The fifteen years that elapsed between my first fieldwork and the events described in chapter 4 included the advent of national independence and changes in the organization of national and local health services. These changes involved some loss of village self-reliance. From the villagers’ point of view, there were doubts about whether to trust the care provided by unrelated outsiders: What could be the possible motives for their intervening?

Part II, “Recognizing and defining illness,” is about how to differentiate the particular focus of medical anthropology. It begins with a chapter on leprosy. The naming of an illness is not straightforward; the story of leprosy provides a lesson in the possible hazards of identifying the same illness in different societies. As an example of the power of labels to stigmatize, “leprosy” also has a long history. In the next three chapters, I argue for the definition of disease itself as critical in medical anthropology, both for distinguishing its distinctive scope and for conducting comparative studies. Doubts about the relevance of Western medical categories for comparative social studies of illness emerged as medical anthropology developed. Alternative modes of thought had long been a lively subject for investigation in social anthropology, especially after Lucien Lévy-Bruhl ([1910] 1923) suggested the idea of prelogical thought, but E. E. Evans-Pritchard (1937) showed the coherent logic behind a radically different view of causality. Distinctions between fact and value, particularly between medical facts and social values, were being challenged in the sociology of medicine. Discussions of truth versus belief and the verification or falsification of fact and theory in science became relevant. Thomas Kuhn's (1970) studies of changing paradigms in the history of science reinforced theoretical doubts about the objective and authoritative status of medical and scientific facts. History bore witness to the social relativity and changing nature of accepted ideas.

Illness could be seen as a form of social deviance. Strong and weak forms of relativism were proposed in medical anthropology and, more generally, in social anthropology at large. Within social anthropology, questions of translation and understanding another mode of thought were prominent. Fieldwork in the tradition of Bronistaw Malinowski requires a proper grasp of the local language. How could translation and understanding be possible if there were no bridgehead of true assertions about a shared reality? Claude Lévi-Strauss held that our common humanity and our shared endowment of senses guarantee we see and speak about the same objective world ([1950] 1966: xxv, xxix). The Melanesian of this or that island is a person I might have been: anyone could be anybody. I might have spoken his or her language and used the same modes of thought.

‘The objective reality of disease putatively sets up a basis or independent point of reference in medical anthropology for comparing different responses, even though it is no simple matter to specify their exact scope and boundaries. Medicine is concerned with responses to many particular kinds of disease rather than with arriving at a single definition encompassing all diseases.

Preface

In other societies, traditional frameworks within which illness is explained clearly persist; the challenge for us is to understand their assumptions. We must grasp the underlying notions of what is normal and possible. Many of these had and still have meaningful connections to moral and religious beliefs. But the encounter with modern change and introduced biomedicine can upset these connections. Part III, “The experience of change,” embarks on comparison by shifting to an African setting. An earlier chapter suggested that the leprosy of Biblical times changed from being a matter of priestly rules, taboos, and exclusion to a matter of atonement for sin or guilt; much more recently, the label of leprosy metamorphosed to refer to a problem for secular medicine to treat. This could be regarded as the medicalization of a religious and moral matter. The beginnings of an analogous shift in understanding and approach are the subject of the chapters on Bregbo, witchcraft, and depression. Chapter 9 describes the healing center of Bregbo in Céte d'Ivoire and its prophet healer Albert Atcho. Bregbo is a community of suffering. Atcho explained why some individuals prosper and others fail by proposing a new morality more adapted to the demands of encroaching urban life. His clients came to him with problems of infertility, childbirth, unhappy marriages, dreams of jobs and urban success, and ambitions they could not realize. Atcho called himself a healer and received official recognition as such. He preached a new understanding of the individual’s own responsibility for his or her suffering; for some, he provided treatment through confession and, for others, care in a community of like sufferers.

Considerable continuities exist between the old persecutive understanding of witchcraft and Atcho’s new emphasis on personal responsibility and guilt. Opinions shifted among different observers about whether or not to see what Atcho did as treating witchcraft or as practicing a form of emerging psychotherapy and community care. After reading about Bregbo, I was introduced to Margaret Field’s (1960) study of an Ashanti shrine, published fifteen years before I learned about Bregbo. Many of the case histories and treatments were astonishingly similar. Field was first an anthropologist, later completing her training as a psychiatrist. She returned and studied a large sample of clients coming to the Ashanti shrine. She considered many of the women who complained of witchcraft to be clinically depressed or mentally ill. Her medical training gave her a different perspective on the problems about which the women spoke. Was this difference purely a question of psychiatric bias and different frames of understanding? Or was recognition of the prevalence of mental illness at stake? Psychiatric illness poses special problems of criteria and evidence in cross-cultural diagnosis.

Chapter 11, which focuses on the impact of events, considers whether the stress of change and adaptation to new circumstances affected the prevalence of illness and inclined priests or leaders of cults toward healing as their special activity. In practice, shifting views invite ambivalence and ambiguity. Past modes of thought are not simply repudiated.

Part IV, “Treatment,” begins by examining healing actions in chapter 12. I discuss verbal techniques and moral persuasion, drawing on many insights in the literature to explain Atcho’s healing work. Pierre Janet’s (1919) monumental studies of suggestion and persuasion (as in both religious healing and psychotherapy) are especially relevant. He emphasized the personal qualities of the healer who provides moral direction and examined the power of the healer’s personal relationship to the patient to influence or even restructure someone else’s self-understanding. Not only does the healer provide the patient with support but also with an explanation and meaning for the experience of illness. The effects of repeated one-on-one interviews in molding an eventual public confession were apparent in the Bregbo community. Janet did not neglect the crucial role of the community that encouraged the patient with their support and expectations. Care, rest, and support not only cure but also make up a significant part of the healing treatment.

Returning to Gnau, it was clear that villagers demonstrated support very differently than Westerners do. Their initial approach was to provide a protective isolation of the patient; this could even go to harmful lengths in cases of protracted illness. Behind their approaches were particular ideas about the causes and dangers of illness. They also had a repertoire of substances, actions and gestures, spells, spittings, and invocations to use in healing. Most of these actions were brief and did not seem to require any intense personal rapport. But when someone important to the villagers seemed to be seriously afflicted, then a more complex and elaborate performance could be organized, sometimes involving nearly the entire village. The ritual healing took the form of symbolic enactment, almost like a theatrical performance, in which the presumed cause of the illness, taking the form of a mask or contrived image, was brought into the village, honored, presented to its victim, entreated, and finally sent away or “killed.” The villagers symbolically made visible the cause, its placation, and its ending in a form of make-believe. Chapter 13 describes one such treatment, the performance of Panvet. The appendix

Preface at the end of the book transcribes in detail exactly what participants said and how they behaved during one particular Panu'et performance.

My final chapter, “Faith and the skeptical eye,” focuses on belief and questions of efficacy. Healing activities can have various functions even when causality (in our terms) is not certain. In hopes of relief, a great variety of treatments may be tried. Some people are ready to believe in miracles; for others, experience brings skepticism. Different aims and different expectations guide judgment. Questions of therapeutic efficacy—of cause and effect—are almost always difficult to answer. Compliance normally requires a willingness to believe a treatment might work. People may also question whether to trust someone else’s judgment, skill, or knowledge or whether to accept what has been done in the past. The shared beliefs and opinions of people in one’s own community, as well as the advice of specialist authorities, potentially carry great influence.

‘The sufferer’s view of success or failure is not always the same as the outside observer’s view. They do not necessarily judge by the same criteria or have the same hopes and expectations. ‘The anthropologist may wish to go beyond observation to analyze people’s activities and attempt to account for the outcome. Lévi-Strauss’s essay on the Kuna shaman’s chant for a woman in protracted labor is a famous example of this. But if an anthropologist explains success or failure in the terms of an external observer, he or she implicitly has to choose and justify the standards used. For an obstetrician (as for other medical specialists), the diagnosis and prognosis are vital for judging evidence of an effect. Follow-up, numbers, and records of failure and success would normally be expected in Western medical practice. Should anthropologists adopt different standards because the people observed do likewise? Anecdotal evidence is not enough.

Belief is not necessarily an all-or-nothing matter. Nor is allegiance to a single type of treatment a general rule. Pluralism rather than a monolithic adherence to one method and one truth better characterizes many practices in treating illnesses. The distress that can arise from demands for unswerving belief is illustrated by the predicament of a New Guinean pastor I knew who fell ill and had to choose between the local health service approach and a ritual treatment based on the non-Christian beliefs and traditions of his people. It posed a moral dilemma for him, revealing the subjective problems engendered in outlooks and beliefs that are undergoing change.

Franz Boas (1966) recorded the experience of ambivalence vividly described by Quesalid in recalling his own initiation to shamanism as his belief changed into skepticism. Likewise, in relation to Gnau treatments involving the extraction of malevolent arrows, we may ask about the sincerity of individual actors’ belief in the actual or the symbolic efficacy of what they did. Issues of doubt and skepticism affected attempts to manage the treatment of leprosy in the village. People were less than ready to voice their opinions and doubts or to comply with the new treatment regimes demanded of them.

‘The treatment of leprosy brings out the impact of prognosis and timing on perceptions of cause and effect. According to Leviticus, the priest could decide on an uncertain diagnosis of this illness by whether the signs had changed after seven days or, in certain circumstances, after waiting another seven days. But the pace and nature of change in the signs of what is now meant by “leprosy” have none of those characteristics. Signs take far longer to change. On questions of cause and effect, knowledge of the facts about diseases may become relevant to explanations and judgments of efficacy, but for the sufferer, other criteria, such as considerations of care, familiarity, and safety, may matter more.

xviii

PaRT I: BEING ILL

This part describes illness and the range of local responses to it in a small New Guinean village I observed during my first period of fieldwork in 1968-69. At that time, the village was difficult to reach and had relatively little exposure to introduced Western biomedicine. ‘The villagers had to meet a diverse range of medical problems largely reliant on their own resources.

To shed light on local illnesses and treatments, I show how villagers responded both to the small ailments of daily life and to serious sickness. Two contrasting cases are described in detail: one of acute panic and community response, the other of long suffering and gradual abandonment. They raise questions about care and their perceptions of the justice or injustice of suffering. During a later field trip fifteen years later, after national independence, access to health centers and aid posts had changed. It involved some loss of village self-reliance and raised problems for the residents in understanding the obligations and motives of the new health providers.

I begin with a brief review of the history and evolution of disease in order to ask what has been the role of human responses to illness in the rise and success of human populations.

Chapter One

Hesiod’s poem “Works and days” tells the story of Pandora’s box, the great grave jar from which misfortune was let loose upon the world. Ils came silently while hope remained shut up inside it. Prometheus stole fire from Zeus, who in anger planned for grief to come to humans:

Till now in peace all the days of the earth had run;

The tribes of men had been saved from the toil that drives,

And disease that flings the swarming Fates on our lives.

But Pandora lifted the jar’s great lid, and then

Its plagues were scattered abroad, with mischief for men.

Only hope remained, entrapped for evermore. (Hesiod, in Higham and Bowra 1938: 132)

It was the loss of a Golden Age when people had been free from toil, suffering, and disease. Similarly, in the story of Adam and Eve’s fall, a paradise was likewise lost. Since then, have people changed or is it diseases that have changed? This was the question to which Sir Thomas Browne gave an answer in his “Letter to a friend,” written around 1656:

Some think there were few Consumptions in the Old World, when Men lived much upon Milk; and that the ancient Inhabitants of this Island were less troubled with Coughs when they went naked, and slept in Caves and Woods, than Men now in Chambers and Featherbeds. Plato will tell us that there was no such Disease as Catarrh in

Homer’s time, and that it was but new in Greece in his age. . . . Some will allow no Diseases to be new, others think that many old ones are ceased; and that such which are esteemed new, will have but their time. However the Mercy of God hath scattered the great heap of Diseases, and not loaded any one Country with all: some may be new in one Country which have been old in another. New Discoveries of the Earth discover new Diseases: for besides the common swarm, there are endemial and local Infirmities proper unto certain Regions, which in the whole Earth make no small number: and if Asia, Africa, and America should bring in their List, Pandora’s Box would swell, and there must be a strange Pathology. (Browne 1977: 399)

This could almost be the justification for a medical anthropology.

In Ancient society, Lewis Henry Morgan saw human history differently from Hesiod’s grim view of a decline from a Golden Age to an Age of Iron: Morgan saw progress not decline. He worked “to bring forward additional evidence of the rudeness of the early condition of mankind, of the gradual evolution of the mental and moral powers through experience, and of their protracted struggle with opposing obstacles while winning their way to civilization” (Morgan [1877] 1964: 11). He followed two lines of investigation: first, into the “great sequence of inventions and discoveries which stretches along the entire pathway of human progress”; second, into the development of certain social institutions from a “few primary germs of thought.” To have survived or not is a matter of the facts: it is the criterion of success according to the theory of natural selection. By that criterion, the human species has been successful: the species has progressed from being rare to numbering in the millions today.

We inherit our genes and with them various potentialities and susceptibilities. People can find food in very different environments, obviously an advantage for survival. “We eat all sorts of things,” a New Guinean man said to me with a cheerful laugh. “You White people choose only the good things to eat, you haven't got strong teeth to eat the things we do, you cant chew up the bones.” But though physiological versatility and flexible development are vital to adaptation, the evolutionary mechanism is genetic. Genes are the basis of characteristics that will potentially be shown by the organism in any environment in which it is able to develop. The genome remains the same whatever the conditions in which the individual organism grows to maturity. Acquired characteristics do not alter the genome. Indeed, it is fortunate that this is so, since most acquired characteristics in nature are the consequence of injury, starvation, disease, or senescence; only a minority are adaptive. The inheritance of naturally “acquired characters” would more likely lead to a deterioration of a species rather than to adaptive advantages (Maynard Smith 1966). The paradox of social evolution, Lamarckian though it is, is that we tend to assume the opposite and suppose that the changes we choose to make are improvements—progress rather than deterioration—because people have exercised choice, as though what people choose and like must naturally be good for them. When people can change their environment through choices and by means of skills they learn, the effects may last, significantly changing the conditions to which their children and descendants must adapt. In this sense, perhaps the effects of acquired characteristics will be inherited and may lead to genetic change in the long term.

Adaptive fitness is decided in a particular habitat here and now; nature pays no regard to a hypothetical future. However, the fate of any population will depend not only on the particular environment in which it lives now but also on whether it will be able to tolerate change. If we introduce time and speculation about the future, we alter the basis for deciding about fitness for survival. In retrospect, adaptations that were favorable in the short term may prove unfavorable in the long run. People can alter their behavior to benefit by learning from the experience of others; learned behavior leaves open a possibility for future change despite present choices. In this lies the human species’ great potentiality: the diversity of cultures. In comparison with other species, human behavior is less fixed, more guided by reason, and more flexible to change and new circumstances.

Diseases in history

Evolution and biological adaptation provide some answers about disease change and human progress. History certainly supports Browne’s observation that “new discoveries of the earth discover new diseases.” The distribution of infectious diseases has played a significant part in the peopling of continents and historical events. In his survey of the global role of infectious diseases through the ages, William McNeill (1976) identified the major disease pools and their spread through encounters and intermingling among people through war, conquest, trade, and pilgrimage, following links between town and countryside, disseminating to different city-states and countries, and crossing mountain ranges and oceans. The ability to survive or the tragedy of succumbing to new diseases mark the history of contact, conquest, and colonization.

Diseases acted as barriers to the expansion of the Chinese beyond their southern frontiers. To the south lay fertile lands with a warm, wet climate, but to settle and thrive there, the invaders needed to accommodate to new endemic diseases and heavy parasite loads. Epidemics have provoked political instability and wreaked catastrophic effects on numerous populations. The conquest of Mexico is a notorious example of epidemic decimation. The exchange of diseases between the Old and the New World was not equal. The Old World had adapted to certain illnesses through gradual exposure over the millennia attendant upon contacts between Asia and Europe, the impact of the Mongol Empire, the Black Death, the effects of expanding communication, and trade by sea and by land. By contrast, the New World and Oceania were confronted with the sudden transoceanic introduction of diseases from the Old World, with catastrophic consequences. Few if any truly isolated societies now remain.

After an epidemic wreaked its toll, a gradual equilibrium tended to emerge, with the populations becoming less vulnerable to disastrous epidemic diseases. They entered a new era of disease proliferation when the balance changed from epidemic to endemic patterns. By the sixteenth and seventeenth centuries, populations in Europe began to grow. As McNeill (1976: 210) points out, “Europe’s expansion is such a central fact of modern history that we are likely to take it almost for granted and fail to recognize the quite exceptional ecological circumstances that provided sufficient numbers of exportable (and often expendable) human beings needed to undertake such multifarious, risky, and demographically costly ventures.” In the complex of factors sustaining Europe’s expansion, McNeill argues that the altered pattern of infectious disease was of key significance.

The identification of causes of change

‘The rise of human populations is a sign of adaptive success of the species. In modern times—the last three centuries—an unprecedented sustained rise in the world’s population has taken place. Assessing the contribution of medicine to this population change requires going beyond conjecture. Often facts are missing or impossible to recover. In The modern rise of population, Thomas McKeown (1976) summed up his research on the role of medicine. His identification of various causes for the decline of mortality in England and Wales was influential, creating something of “a conceptual revolution in the disciplines of history and medicine, overturning a long-standing general orthodoxy regarding the importance of medical science and the medical profession in bringing about the decline in mortality which accompanied industrialization in Britain” (Szreter 1988: 2). Any orthodoxy is likely to elicit critical reappraisal. McKeown argued that conjecture is not of much value without reliable evidence. He proposed instead a method of deduction based on explicit evidence by applying reasoning and current medical knowledge to a detailed series of national death records from the past. His analysis was original and persuasive.

McKeown found that, from 1838 onward, new rules of personal registration in England and Wales provided national records from which population size, birth rate, death rate, and causes of death could be calculated. These figures made it possible to discover reasons for the increase in population that occurred. From his examination of the records, McKeown concluded that the rise represented a decreasing death rate rather than an increasing birth rate. He found that the decline of mortality was due chiefly to the reduction in deaths from infectious diseases. Between the period of 1848-54 and 1971, 26 percent of the drop in mortality was due to a reduction in noninfectious mortality, but the largest proportion—74 percent—was due to fewer deaths from infectious diseases. To interpret this finding, McKeown looked for when, to what extent, and which specific infections declined. Not all infectious diseases declined uniformly, since different kinds of such illnesses existed, each with its own characteristics and particular history. We know that airborne diseases, for instance, display different potentials for exposure, risk, spread, communicability, and chances of control as compared to diseases that are waterborne or foodborne. McKeown drew graphs of the decline in death rates over the study period from each particular kind of disease, indicating exactly when an effective therapy for each was introduced. He found that, for the majority of infectious diseases, most of the decline in mortality preceded the introduction of an effective therapy. A few diseases, such as scarlet fever, changed in virulence over time. Rules for public hygiene and the building of sanitation infrastructure reduced the study population’s exposure to infections by water- and foodborne diseases, such as typhoid, cholera, and other intestinal diseases. Changes in the prevalence of tuberculosis reflected reduced exposure after reforms in housing and working conditions were instituted, although class differences in prevalence persisted due to uneven implementation of these reforms. However, these changes did not explain enough of the decline in mortality.

McKeown concluded that the growth in population during this period could not be attributed to fortuitous changes in relationships between disease organisms and hosts. The drop in mortality was not much influenced by immunizations or medical treatments before 1935, when sulfonamide antibiotics became available. Certain medical measures were effective before 1935 in the management of smallpox, syphilis, tetanus, diphtheria, diarrheal diseases, and some surgical conditions, but these had made only a small contribution to the total decline in the death rate since 1838. By the method of exclusion, he was left with one other explanation for the reduction of mortality—namely, improvements in the human environment. Water purification, efficient sewage disposal, and improved food hygiene were introduced in the second half of the nineteenth century and reduced death from intestinal infections, but the decline in infectious diseases had actually begun before then. His main finding was therefore the negative conclusion that, contrary to common assumptions, medical science and hygiene had nof¢ contributed much to this eras decline in mortality. His positive finding was that improvements in nutrition explained the population increase. The most likely explanation, in McKeowr’s view, for the decline in mortality and the growth in population was the improvement in the population’s nutrition due to greater food supplies.