1984; 64:929-933.PHYS THER. Katherine K ParryConcepts from Medical Anthropology for Clinicians

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Concepts from Medical Anthropology for Clinicians

KATHERINE K. PARRY

This article introduces the discipline of medical anthropology and presents concepts that may be useful for physical therapy clinicians. The terms culture and cultural orientations of the United States are defined, and examples of cultural conflict in patient care are given. I explain the differences between emic and etic viewpoints and analyze this distinction in relation to health care in the United States and especially the separation of the concept of disease and illness. Anthropological tools are presented for restructuring encounters between clini­cians and patients to make clinicians more culturally sensitive.

Key Words: Anthropology, cultural; Disease; Medical history taking; Physical therapy.

Medical anthropology, a new discipline within cultural anthropology, offers much to physical therapists who often find themselves practicing in settings with a variety of ethnic groups or predominance of one ethnic group. The field of medical anthropology is concerned with the relationship of culture to sickness, the healing process, and patient-practi­tioner communications. The sources of this new field are varied. Originally, cultural anthropologists collected data on the medical beliefs and practices of non-Western people as part of the total cultural data on them. The impetus to apply this data to the health problems of these people came from the international public-health movement after World War II.1

The failure of health-care clinic personnel to reach targeted populations was blamed on the ignorance and lack of educa­tion of the people being served. Public health and medical workers believed that through education, the superiority of scientific medicine could be demonstrated and could lead to greater acceptance of health-care services.2, 3 When this plan of action led to frustration and failure, health professionals developed a working relationship with anthropologists to de­liver health care that would not be simply a replica of health care in industrialized countries but would be congruent with traditional beliefs and practices of the native population. Concurrently, the values, premises, and practices of health professionals became an object of study because a major cause of frustration was the unexamined assumptions of the health professionals.4, 5

Currently, medical anthropologists are employed in hospi­tals, health departments, and universities, where they conduct research on areas such as the effects of social and cultural factors in the cause of disease and communication problems between practitioners and patients. Research is no longer only concerned with health beliefs of peoples in underdeveloped countries but also with cultural groups in the United States. The study of cultural variations in formal and informal med­ical theories and practices is a subdiscipline in medical an­thropology known as ethnomedicine.6 (p10)

Medical anthropology goes beyond studying health beliefs of specific cultural groups and the consequent danger of accepting cultural stereotypes to examining cultural perspec­tives. The purpose of this paper is to present analytical con­cepts and perspectives from the field of anthropology that may be used by physical therapists to 1) examine their own assumptions and 2) understand how beliefs concerning health and illness are created.

ANTHROPOLOGICAL PERSPECTIVE OF CULTURE

Culture can be thought of as a design for living. A conve­nient way to think of culture is as a blueprint for a building but not the building itself. These designs are passed on from generation to generation to tell people what should be done, could be done, and must not be done.7 Culture denotes regularities or organizing principles distinctive to a group, and these principles are sometimes referred to as "value orienta­tions."8

An anthropologist who considers cultures as having distinc­tive organizing principles moves away from concepts of ad­vanced and primitive cultures and the superiority of some cultural perspectives to others. Rather than judge and com­pare institutions of culture, including medical institutions, anthropology seeks to understand each culture on its own terms and each institution in terms of the culture.

Cultural Orientations in the United States

Cultural beliefs exist to answer certain universal concerns and questions.9 Among the most relevant is a person's rela­tionship to nature, other people, and time. In the United States, the core orientations that respond to these questions are activism, individualism, future-time orientations, and a belief in a person's mastery over nature. Activism implies that the best response to a situation is an active one. For instance, statements like "God helps those who help themselves," "If at first you don't succeed, try again," and "Every problem has a solution," reflect this attitude. A person's relationship to nature from the perspective of activism is a desire to conquer or master nature rather than a feeling of powerlessness before nature or harmony with it.10(pp236-247)

Dr. Parry is Clinical Coordinator, Baptist Hospital, 8900 N Kendall Dr, Miami, FL 33176 (USA).

This article was submitted April 14, 1983; was with the author for revision 19 weeks; and was accepted January 2, 1984.

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Individualism recognizes the supremacy of the individual over the group rather than alternatives such as the supremacy of the extended family unit or the collective society. State­ments such as "This is the ME generation," "I do my thing and you do yours," or "I am my own best friend" reflect the individualistic perspective. The image of the United States as the land of the pioneer spirit reflects both active and individ­ualistic orientations; individuals have conquered the land, manipulated nature, and now control with ultrasophisticated technology.

The cultural time frame of the United States is largely embedded in the future. Time is conceptualized as linear with the past, present, and future on a continuum. With such a concept, we are able to defer present gratification for the promise of future reward.

These cultural orientations are so ingrained that they seem self-evident, but dissonance can occur when these orientations contrast with the values of individuals from other cultures. At times, unexamined assumptions that clinicians hold can bias treatment planning as well as lead to frustration or even hostility.11

Case Example

A physical therapist who worked on an Indian reservation in the Southwest of the United States reported several frus­trating problems. Many patients did not keep their appoint­ments, and when home visits were scheduled as an alternative, often the patients were either absent at the appointed time or unwilling to accept treatment because they had something else to do. Another problem centered around an unwillingness to follow treatment plans. Patients would not do exercises that were prescribed to prevent contracture, and they refused canes and crutches. Other isolated incidents of patient non­compliance indicated conflict between the expectations of the therapist and those of the people. For example, an 8-year-old girl with juvenile rheumatoid arthritis checked herself out of the hospital against medical advice but with parental consent. Also, a lecture given by the physical therapist about body mechanics was met with embarrassed giggles.

Most of the patients were elderly women who were friendly and not evasive. They listened carefully and patiently to all instructions, but when asked directly if they intended to follow them, they said "not really." They reported that they liked the clinic but not for the reasons the therapist expected. For them, the clinic was a place to see their friends and to get heat treatments, which they thought were very beneficial. The people in this community also consulted chiropractors, pri­vate physicians in a nearby town, and native healers from other reservations.

In analyzing this situation, several factors should be consid­ered to explain the difficulties the therapist encountered. Was the noncompliance in this situation the result of cultural differences or mistaken assumptions and expectations or both? What were these cultural differences? Whose assump­tions were mistaken?

The physical therapist in the above example was a doer. Her response to a challenge was to take action and to try to master the situation. Furthermore, the therapist was future-oriented—to perform exercises now to prevent a future prob­lem, such as contracture, from occurring. This contrasted sharply with values of the Indian group. Their response to

challenge is not "doing" but "being" coupled with a desire to harmonize with, rather than overcome, the forces of nature.

Time orientations were a matter of conflict. For the people receiving treatment, only the present held importance because the future was uncertain and very possibly suspect. Naturally, this made keeping appointments difficult. Obligations to fam­ily and relatives also came before obligations to strangers so appointments were easily canceled in the face of other prior­ities. The Indians' attitude of living for the day and taking their chances for the future conflicted with the therapist's expectation that the patients would follow directions for the sake of future benefits.

Individualism was apparent but was demonstrated in a different manner than in the culture of the therapist. Individ­ual autonomy was encouraged at a young age, and children were expected and allowed to make important decisions con­cerning their welfare. Thus, the Indians thought an 8-year-old child signing out against medical advice was quite natural.

The relationship between the patient and the physical ther­apist was confounded by the relationship of the people with native healers. This latter relationship was traditionally fraught with fear and suspicion. Because such people were believed to possess powers to heal, they also could be danger­ous enemies who could use these powers to harm. The result was that no stable set of expectations developed about how the patient should behave with health professionals. The lack of congruence between the values of health-care deliverers and the people they served resulted in conflicting expectations that promoted untrue assumptions about the delivery of patient care.

Compliance and the Clinical Setting

Physical therapists often treat patients for chronic, long-term conditions that necessitate change or modification in life style. The therapist expects that the patient will comply with the treatment. Parsons has noted that this expectation is part of a role that individuals in our society take on when they are defined as sick.12

Health professionals should examine their own cultural attitudes and assumptions behind the word "compliance." This word is truly representative of core values in the United States and indicates a hierarchical relationship where one person obeys another for the good of the individual. Compli­ance implies that an action is chosen in the present to benefit the future. Not only is this a value-laden term, but it implies a one-way flow of information from practitioner to client rather than a transaction between two parties.13 (pp829-830)

It has been suggested that patient treatment should follow a model of mutual participation in which therapists conceive of their role as helping the patients help themselves to achieve the therapists' goals. Because this model requires complex social and psychological organization on the part of the pa­tient, however, this approach is not appropriate for patients who have no background or set of precedents to share in such a model.10 (pp33-51) As in the previous case example, seeking help for oneself may be a threat in cultures in which the family or other social networks are more important than the individuals. A set of behaviors that threatens to change a role in a family would be viewed as displaying selfishness, disloy­alty, or even hostility.

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PRACTICE

Although the patient's illness or disability may be in the forefront for the therapist, the illness is only one part of the life of a patient. Outside of the acute stage of illness, focal concern for the disease is not sustained in everyday life. Freidson noted:

When the patient merely visits a medical setting periodically and briefly, coming from and returning to his kin, friends, and neighbors... illness becomes primarily organized by the life of the lay community.14

Many factors work against patient compliance beginning with the assumptions that are built into the word itself. The values that compliance connotes to each individual coupled with an insufficient understanding of the patient's construc­tion of his illness and expectations can lead to frustration. This frustration may be exacerbated when dealing with the patient from ethnic groups other than one's own.

ANTHROPOLOGICAL CONCEPTS—ETIC AND EMIC

Each culture determines what people perceive to be a symptom and who should be contacted to treat it. This is an important point because a current problem in medical-care delivery is not recognizing that each culture, including our own, has its own definition of what constitutes illness.15,16

In anthropology, a distinction is made between the insider's perception of the situation and the outsider's analysis. An etic view is composed of analytical language such as concepts and theories. When I define "mal ojo" as a traditional Mexican American folk illness afflicting children and women, mani­fested by vague symptoms such as fever and nervousness, and said by local people to be caused by inordinate attention or covetous expressions, then I am offering an etic definition. An emic view refers to the native view or the insider's view. For instance, when Mexican Americans speculate on who might have caused "mal ojo" in their child, this is an emic speculation that makes sense to those who share the culture and language. On the clinical level, when an elderly black patient is referred to the clinic with a diagnosis of radial nerve palsy, that diagnosis is the etic view of the medical system in which I was trained. When he suggests that this "nerve dis­ease" might be caused by exposure to the cold, and his wife believes that it might be the result of rootwork (caused by a hex), I am hearing the emic perspective.

A problem can result when etic terminology and emic terminology are identical in vocabulary but mean different things, assume different origins, and may result in different consequences. The elderly black patient and I both agree that his illness is a "malfunction of the nerve" but what those words mean to both of us is different. My treatment rationale, while making sense in my system, may not make sense in his and may limit his participation and compliance. Only explain­ing my perspective and expecting his understanding is one­sided and assumes that his perspective is somehow the defi­cient model.

A second problem occurs when etic categories or medical diagnoses bypass health problems described in emic terms that are culturally defined and understood by the patient but are different from the diagnostic categories and meaning the health professionals assign to the problems.13 (p586) Weidman isolated a complex emic syndrome known as "falling out" among Southern blacks and other groups.17 This condition is

characterized by fainting spells and loss of consciousness and is attributed, in part, to "high blood." The symptoms can progress to a stage in which the sufferer is incapacitated and may be terminal. To orthodox practitioners, "falling out" is treated as a peripheral problem. Etically, the syndrome is considered and treated as a hysterical or a "functional" dis­order. Because "falling out" is not viewed as a syndrome in its own right, the condition is not treated despite the possibility of disability and, in some cases, death.

Illness and Disease

From the point of view of medical anthropologists, the scientific perspective is an emic model. As Engel stated

The historical fact that we have to face is that in modern Western society, biomedicine not only has provided a basis for the scientific study of disease, it has also become our culturally specific perspective about disease, that is, our folk model. Indeed, the biomedical model is now the dominant folk model of disease in the Western world.18

Examination of the biomedical system as a model has led to a distinction between the terms "disease" and "ill­ness."15,19,20 Separating these terms is a necessary consequence of the evolution of Western medicine.

Originally, in all societies, the main criteria for identifying disease was behavioral, social, and psychological changes or deviations of individuals in groups. These deviations poten­tially disrupted social functioning, and all societies responded to this disruption by appointing individuals and creating institutions whose function was to evaluate, interpret, and correct these deviations. The institution of medicine and physicians as professionals evolved as one response to this problem. What is termed pathological or what may be consid­ered as an illness or a disease is relative to social convention and based on changing criteria.

The mainstream of Western medicine has defined disease as a deviation from the norm of measurable biological varia­bles. Each disease is assumed to have a specific etiology and specific and distinguishing features universal to humans.6(p9)

With these assumptions, disease has become objectified and pulled out of its social and environmental contexts.

Disease in this framework is something that can be caught, like a cold, or that invades an individual, like cancer. Disease can be diagnosed by blood chemistry or by high technology equipment in a manner that often does not require much input from the individual other than passive cooperation. Disease is what scientists study. Illness, on the other hand, is what people experience. It is the person-centered deviation or discontinuity associated with discomfort or impairment. The main point is that medicine has the task of understanding and treating illness. Understanding cannot be done solely by specifying disease in terms of biological signs and symptoms because "although bodies have signs and symptoms, only people become sick."21

As Kleinman pointed out, medical care has focused on controlling the biological malfunctioning of disease at the expense of effective treatment for psychosocial problems as­sociated with the illness experience.22 Use of the disease model has produced a situation in which an individual may feel ill but be told that he or she has no disease. Often this results in physicians labeling patients "crocks" or hypochondriacs. Con­versely, an individual can be diagnosed as having disease in the absence of any personal indicators of illness.

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Young has written that therapeutic cures must meet the expectations of the sick person and his kin:

Therapies are not only a means for curing illness, but equally important, they are a means by which specific, named kinds of sickness are defined and given culturally recognizable forms.23

This distinction between disease and illness is germane to the example of the elderly black patient with radial nerve palsy. Although his problem was given a disease label that directed my treatment, his illness and its ramifications, in­cluding his search for etiology, could go unrecognized and untreated. This oversight may send such a patient to alterna­tive practitioners, such as herbalists or chiropractors.

ANTHROPOLOGICAL SOLUTIONS

Anthropology offers two perspectives that can be useful in making health care more acceptable to diverse ethnic groups. The first, ethnography, a central tool in cultural anthropology, involves getting a mental mapping of the patient's world. In other words, the clinician strives for the emic view by learning the patient's definitions and seeing the world from the pa­tient's point of view. The therapist needs to know from what the patient believes he or she is suffering. A doctor's diagnosis, though medically correct from an orthodox point of view, may not be at all representative of the patient's view of the situation. Sometimes the success of a treatment is incidental to the official explanations of the problem, and the patient's acceptance of a treatment is based on a rationale totally unrelated to official reasons. For instance, on the Indian reservation, hot packs and heat treatments were successful because they fitted into the acceptable treatment rationale on the reservation. Diseases were classified as "hot" or "cold" and hot illnesses were to receive hot treatments. As one might imagine, this folk belief also promoted the use of products like topical deep-heating ointments and the application of "hot sticks" to the joint surface to draw out the heat. By learning the patient's definition of his illness, the therapist demonstrates an interest in restoring the patient to his world.

Patient's definitions can be elicited by asking questions that draw out the "explanatory model" of the patient's conditions. Blumhagen compiled a list of questions as an example of the explanatory model.24

1. What do you call your problem? What name does it have? 2. What do you think has caused your problem? 3. Why do you think it started when it did? 4. What do you think your sickness does to you? How does

it work? 5. How severe do you think your illness is? Do you think it

will last a long time? 6. What do you fear most about your illness? 7. What are the chief problems your illness has caused for

you? 8. What kinds of treatments do you think you could receive? 9. What are the most important results you hope to get from

your treatment? Blumhagen suggested that these questions may result in a "contradictory model," but by bringing forth these contradic­tions and asking further questions, a deeper understanding of patient perceptions might be achieved.24

Another way to learn about health beliefs is to read infor­mation that pertains to the patient's ethnic group. Harwood produced a volume that outlines the health beliefs of seven cultural groups in the United States.25 This information can give a general background that can be used as an adjunct to the interview questions. For instance, I might ask my elderly black patient a question such as, "Some people think rootwork has caused your problem. What do you think?" In this fashion, his beliefs about etiology and remedial actions can be ex­plored. This type of question also tells the clinician in which areas the beliefs of the individual conform or deviate from the beliefs of the ethnic group as a whole.

The second approach to better health care for diverse ethnic groups is the use of the transcultural concept. At present, the majority of health practitioners operate under a unicultural concept. This is the assumption that "scientific medicine" is the correct practice, and all other beliefs and practices about health care fall under such labels as folk beliefs, lay medicine, ignorance, superstition, and quackery.26 Although the usage of terms such as holistic health, holism, and the whole person is increasing, these terms are sometimes too broadly defined to be functional. Press stated, "Definitions of the 'whole person' vary wildly (not just widely), and include an array of elements from the mundane to the astrological."27

One way to acknowledge the covalidity of belief systems is to consider them as "cocultures."l3(pp819-847) In doing so, the practitioner recognizes that the conceptual system of patients is just as deep-rooted and integral to their sense of well-being as is the clinician's cognitive structure. This kind of approach requires placing oneself at a distance from both of the health cultures so that the health professional, in a sense, becomes a negotiator. Clinicians may need to negotiate with patients when they want to diminish or eliminate behaviors that might hamper treatment or elicit cooperation and acceptance of the treatment regimen.

SUMMARY

I have outlined several sources of possible conflict in treat­ment of ethnic groups and proffered several solutions from medical anthropology. The medical model by itself, focusing on disease rather than on the illness experience, does not prepare its practitioners to deal with the cultural, social, and psychological construction of the problem by the patient and his or her family. The value orientations of the United States outlined previously operate at times without recognition of the expectations that are generated by them. The expectation is that congruence of activity and time orientations as well as congruency of relationships will occur. Word choices such as compliance imply all three expectations. The core values of the patient, however, may go unrecognized. Indeed, many times, practitioners assume that a patient comes to therapy like a blank slate waiting for instruction as though no behav­iors to maintain health existed. The rather one-sided view underestimates the depth and rootedness of the patient's health beliefs before contact with the health institution. Un­derstanding the patient's explanatory model and negotiating the treatment regimen with him are alternative solutions. Such an alteration in perspective should lead to decreased alienation and improved health-care delivery for those who otherwise drop out, withdraw, or are "lost" to follow-up.

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PRACTICE

REFERENCES

1. Foster G: Medical anthropology: Some contrasts with medical sociology. Soc Sci Med [B] 9:427-432,1975

2. Freedman M: Health education and self-education. Health Ed J 15:78-92, 1978

3. Simmons O: Popular and modern medicine in Mestizo communities of coastal Peru and Chile. In Lynch L (ed): The Cross-Cultural Approach to Health Behavior. Madison, NJ, Fairleigh Dickinson University Press, 1970, pp 228-254

4. Levine S, Scotch N, Vlasak G: Unravelling technology and culture in public health. Am J Public Health, 59:237-244,1969

5. Bullough B, Bullough V: Ethnic identity and health care. East Norwalk, CT, Appleton-Century-Crofts, 1972

6. Mishler E: Viewpoint: Critical perspectives in the biomedical model. In Mishler E, Amarasingham L, Hauser S, et al (eds): Social Contexts of Health, Illness and Patient Care. New York, NY, Cambridge University Press, 1981

7. Williams RM Jr: American Society: A Sociological Interpretation, ed 2. New York, NY, Alfred A Knopf Inc, 1961, pp 22-25

8. Kluckhohn C: Values and value-orientation in the theory of action. In Parsons T, Shils EA (eds): Towards a General Theory of Action. Cam­bridge, MA, Harvard University Press, 1951, p 411

9. Kluckhohn F, Strodtbeck F: Variations in Value Orientation. Evanston, IL, Row Peterson and Co, 1961, p 11

10. Bloom S: The Doctor and His Patient: A Sociological Interpretation. New York, NY, The Free Press, 1965

11. Saunders L, Hewes G: Folk medicine and medical practice. J Med Educ 28:43-46,1953

12. Parsons T: Definitions of health and illness in the light of American values and social structure. In Jaco EG (ed): Patient, Physicians and Illness. Glenco, IL, Free Press, 1958, pp 107-127

13. Weidman H: Miami Health Ecology Project Report: A Statement on Ethnic­ity and Health. Miami, FL, University of Miami School of Medicine, 1978, vol I

14. Freidson E: Profession of Medicine. New York, NY, Harper & Row, Publishers Inc, 1970, p 311

15. Fabrega H: Disease and Social Behavior Cambridge, MA, The MIT Press, 1974

16. Lynch L (ed): The Cross-Cultural Approach to Health Behavior. Madison, NJ, Fairleigh Dickinson University Press, 1970

17. Weidman H: Falling-Out: A diagnostic and treatment problem viewed from a transcultural perspective. Soc Sci Med [B] 138:95-112,1979

18. Engel G: The need for a new medical model: A challenge for biomedicine. Science 196:129-135,1977

19. Fabrega H: The need for an ethnomedical science. Science 189:969-975, 1975

20. Eisenburg L: Disease and illness: Distinctions between professional and popular ideas of sickness. Cult Med Psychiatry 1:7-21,1977

21. Engel G: Psychological Development in Health and Disease. Philadelphia, PA, WB Saunders Co, 1962, pp 185-199

22. Kleinman A: Lessons from a clinical approach to medical anthropological research. Medical Anthropology Newsletter 8(4):11-14,1977

23. Young A: Some implications of medical beliefs and practices for social anthropology. American Anthropologist 78:5-24,1976, p 8

24. Blumhagen D: The meaning of hypertension. In Chrisman N, Maretzki T (eds): Clinically Applied Anthropology: Anthropologists in Health Science Settings. Dordrecht, Holland, Reidel, 1982, pp 297-323

25. Harwood A (ed): Ethnicity of Medical Care. Cambridge, MA, Harvard University Press, 1981

26. Weidman H: On getting from "here" to "there." Medical Anthropology Newletter8:(1)2-7,1976

27. Press I: Witch doctor's legacy: Some anthropological implications for the practice of clinical medicine. In Chrisman N, Maretzki T (eds): Clinically Applied Anthropology: Anthropologists in Health Science Settings. Dor­drecht, Holland, Reidel, 1982, pp 179-198

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