Brian Altonen, MPH, MS

Culturally-bound Syndromes, Part II

WORK IN PROGRESS

Foreward

This is a continuation, and in some cases, delving into further detail on some topics covered in the Population Health section of my blog.  As usual, the evidence I am about to present is based on three routes taken during my 30+ years of study and related teachings in the university setting in Portland, Oregon.  Over the years I reviewed related topics based on historical documents and studies, engaged in anthropological research as a part of my plants in medicine course at the university, and the usual expectations of someone engaged in lab research on medicine and plant chemistry for more than 17 years. 

Introduction to Part 2

What is the meaning of the term “culturally-bound”?

The original use of the term ‘culturally-bound’ referred to specific observations linked to a particular cultural setting.  These links were based on unique beliefs contained within the cultural setting researched.

When used to refer to medical conditions or syndromes, the meaning of this term has taken a twist in recent years, and has become a term assigned to any of several types of population medical features which have either a direct and historical association to the medical observation, or is assigned to medical condition that according to some researchers has an internal culturally derived reason for the conditions.

In a recent revierw of the term culturally-bound in relation to disease states, the traditional non-US and non-Western medical conditions were noted–conditions related to a specific ountry or culture–but it was also found that a number of researchers have come to relate this term to diseases or conditions that have often been considered mostly a medical condition linked to highly developed countries like the United States, such as Anorexia nervosa or ADHD.  In the latter group, the disease is considered a product of society itself, allowing “culture” to become a subjective term applicable to United States culture as well.   In other words, just as some medical conditions like the fear of cold,or too much exposure to easterly winds, or fear of coming up against the devil are related mostly to certain well-defined cultural belief systems, so too are some of the chronic conditions that disappear or reduce in prevalence for unknown reasons attributable to the cultural belief system of the United States.   This type of disease development assigned a sociocultural reason for disease creation and development, reasoning which try to define how these attributes can somehaow impact the psychosomatic cause for disease onset (see Kirmayer and Young’s 1998 work on this).

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The evolution underlying the inclusion of this particular feature in medicine endured several stages over the past two centuries.  Culturally-bound syndromes were documented mostly as historical anthropological events with underlying philosophical and religious overtones that seemed to play important roles in their development and maintenance for generations to come within any given society.  This view of the diseases that individuals from other cultures were experiencing was a consequence primarily of writers applying an ethnocentric approach to their work–the supposition being made was that ‘we are right, in our philosophy and science, and they are wrong.’    Anything “unique or different” that a culture being observed believed in was interpreted largely based on the belief system of the individual witnessing these events.  Throughout history, this has resulted in the publication of articles claiming such things as the belief that Oriental medicine with its non-Western herbalism and its reliance upon five elements and yin and yang is “primitive” or “barbaric”, or that the Indigenous beliefs in “invading spirits of elders” is nothing more than “superstitious” or beliefs akin to “witchcraft.”

Like any normal person, even though these observers were scientists, physicians and religious leaders, they almost subconsciously had to perceive the events they witness based on their understanding of the world.  Nearly all observors of other cultures during the 19th century are ethnocentric in some way, and their writings which helped direct the growth of the medical anthropology field in the twentieth century has allowed many of these methods of analysis and beliefs to continue. The interpretation of cultural disease patterns was/is a different course of study than the scientific study of diseases and their treatments. The former is a different form of cultural interpretation than the latter. Both are very much subjective in nature, only valid for the time due to ever changing belief systems, and no longer applicable once the society in charge of such studies and the society undergoing these studies switch roles.

Until the field of anthropology came to be, science did little to try and understand how the other culture came up with its findings and beliefs.  Science instead used its own methodology to study these claims and any related events that were witnessed.  The summaries then made about such came were then presented in the context of the most modern scientific beliefs for the time (recall my mention of ‘transformation of common belief’ claims regarding important parts of these research practices–scientists chose to accept of condemn a result of a remedy, and if they accept it, have to explain it as part of their paradigm on life and medicine–thus the medicine worked by fire, then by some chemical, then by a specific and very selective toxic effect upon the body)

In United States history, Medical Anthropology became the field of choice soon after the Civil War ended when some government workers and researchers began to better define this field of study.  Medical anthropology was then focused on trying to understand the psychology and philosophy of the shaman in a more scientific fashion, related to the contemporary scientific views of the mind, body and disease relationship.  Medical anthropology was also focused on learning the details of the medical botany of many cultures, with hopes of finding new medicines.   The findings of medical anthropologists often preceded those engaged in by researchers of science and medicine.  Prior to the 1920s for example, the Native American was identified as physiologically unique doe to the tendency of life on the reservation setting to result in heavy outdoor recreational practices–such as playing native games on foot or engaging in long runs from one part of the territory to another in order to share news with other families.  This resulted in the publication of an article on what is today called athlete’s heart syndrome in indigenous people engaged in such behaviors.  In fact this healthy heart was due to the limited transportation means these people had, or were provided with by the US government.   Younger men frequently had to engage in such communication practices due to limited technology and engineered equipment within the reservation setting.

Decades later, as many of the most important multi or cross-cultural discoveries were reviewed further in medicine, and as a result of governmental provisions provided to indigenous settings, certain health changes took place.  The most prominent and famous of these changes (it’s now centuries past the infectious disease period in cross-cultural infleunces, such as exposure to small pox, and well into the environment, sanitation-based disease stage in cultural development) was the development of a life-long chronic disease in Native American communities, American Indian and Inuit.  The Hudson’s Bay trapping facilities had introduced new foodways to the tribes in Canada, and by 1880, the first documented cases of diabetes were noted for this culture.  Much later in this development of diseases within the indigenous social setting, we find the application of the “metabolic syndrome” diagnosis to this state, which until then had its own unique medical anthropological names.

During the 1980s, for example “metabolic disorder” was preceded by the medical anthropological name of “New World Syndrome.”   That in turn was preceded by the anti-starvation gene theory proposed during the 1920s.  The best fit to this disease pattern remains the anthropological method of designing the malady, for the common allopathic method using the ICD-9 taxonomy only partially defines the particular form of metabolic syndrome that Pima Indians and other assimilated or partially-modified Native American lifestyle practices have resulted in this common obesity related malady suffered by Native Americans.

The following topics covered provide a little more detail of the conditions covered previously in the Population Health section, along with a number of new topics added.  This section uses the same unique approach of demonstrating these disease behaviors as demonstrate on the population health pages.

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The above collage relates to Culturally-bound syndromes in several ways, and some of the images were selected due to their multiple interpretations and meanings.

These images relate to ICDs used to demonstrate the meaning of “culture.”   Culture is a very ethnocentric manner of interpreting or classifying certain conditions.  This attitude about certain ICDs is becoming a more common feature is the alternative medical writers–that is to say the university authors who pay more attention to where the barrier is defined between right and wrong, normal and not so normal, western medical and non-western medical, traditional and non traditional.  The kinds of topics inferred are:

• Sainthood and the definition of miracles
• The definition of a “healthy” body builder
• The ill-lady versus the Salem (or Hudson Valley) “witch”
• Social fears and social “epidemics” of hyperreligiosity
• Social rage vs. outrage
• “skinniness” vs. anorexia
• seized by the “falling sickness” or simply hyperactive
• tension and the migraine
• worry and anxiety
• obsessive-compulsive versus agoraphobic
• autoimmune and/or the mind-body relationship
• chemical depression versus reactive depression
• metal poisoning or a victim of poverty
• unable  to manage aggression and/or a sociopath
• personal and social belief, mind-body manifestation, versus sorcery and ‘quackery’
• feng shui, the environment and the asthmatic
• interpretations of self and the environment–internal locus of control vs. external locus of control

The sources for our knowledge are culturally defined.  The health belief model is used to explain disease development and healthy/unhealthy responses to health information and behaviors based on knowledge base, our belief system, what we are taught by our family and peers, and what we are allowed to engage in socially in order to appease those desires for the “perfect body”.  The mind-body influence and social-personal influence have a significant impact on our good looks as much as on the progression of our disease states, the ability for a medical care provider to make his/her diagnosis, and even the ability for health care givers to recognize “proper” health care practices.

Culturally-bound syndromes have traditionally been those medical conditions, mostly “illnesses”, that are bound to specific belief systems and cultural settings.   Due to the upbringing and knowledge base of a particular cultural setting, individual believe a particular disease occurs due to conditions that require a specific line of training and philosophy to be understood.  The cultural standards for the time in Hudson Valley, NY in 1800 dictate that the condition that a young girl is experiencing, who is polylalic and verbalizing pseudo-latin gibberish, while appearing asleep in bed, is a lady gifted with the ability to communicate with some ‘Higher Power.’   A physician focused on the climate and disease theories popular for the time might have defined her state as that of an individual unable to tolerate the intense humidity of the area for the time.  An individual focused on the importance of inner workings and temperament upon the human body’s health and outcome might have claimed her mental anguish was the result of poor physique and trying to survive in a region her family was not that adapted to.

Even today, physicians trying to understand her condition might have come up with the theory that she is suffering from hyperreligiosity and epilepsy, or some sort of schizophrenia or dissociative disorder, or is psychologically and voluntarily engaged in some sort of behavior designed to develop a following, perhaps some sort of narcissistic activity or sympathy-gathering attempt.  Whatever the reasons for her behavior, the diagnosis of her condition at the time required the physicians trying to better understand her come up with a philosophy, logic and official naming of her mental and physical health status–New York’s congressman and physician for the time Samuel Mitchell so named this medical state “Divine Somnambulism”, claiming she was in some sort of semiconscious state between wakefulness and sleep, during which time she became capable of connecting to some other state of being and those other parts of the universe that normally we do not connect with.   This was the culturally-bound syndrome for the time in New York, a condition that prior to the early 1800s was possibly linked to such prior events as the local “manias” occasionally experienced in the form of group overly vocacious religious activities, those religious revival permeating the lower parts of New England and New York.

Due to the detailed nature of how science is used to explain the body and health, science comes up with these arguments that are used to explain how and why certain events occur regarding their patients’ health.  Physicians often like to define a syndrome with a certain amount of sociocultural context put into play.  When a child going to school has a problem socializing due to fears developed as a result of teasing from others in his/her age group, this experience has a medical name attached to it.   “Gelettophobia” is the problem the famous character Pinocchio experienced due to social reaction to his uniqueness in the social setting for his age groups.  Gelettophobia is ‘the fear of being laughed at.’

“Pinocchio Syndrome”

This condition is culturally defined, but relies upon accepted status quo regarding cause and effect.  In one cultural setting, the reasons for ridicule may be very different from those of another cultural setting.   In  order for such a diagnosis to be acceptible, it must have support of both colleagues and overseers of the profession involved.  This support in turn is provided based on the sensitivity of these individuals and groups to the terms and methods involved in establishing this diagnosis.   Based on culture and tradition, we can stereotype some personal psychological and psychosocial practices, but not others.   Culturally-based social interactions at school related to some African-based physiognomonic features, are less likely to be given the same name and treatment, yet are common to American society.

Whereas Pinocchio syndrome is very much a syndrome developed due to interpersonal perspectives, and is a result of shape and form for which no illness may be attributed, other syndromes with physical illnesses and biological causes attached to them have uniquely different interpretations that can be developed.  In the case of the Sudden Unexplained Nocturnal Death Syndrome (SUNDS) related to immigrants from Thailand, Vietnam, Cambodia and Laos, sudden deaths at night were interpreted by western physicians engaged in a western knowledge base and the attached western paradigms.  A psychological or psychiatric cause for sudden deaths seemed impossible to these doctors, and therefore a cardiac based physiological cause had to be sought out.  It may or may not have been defined depending upon one’s point of view.   Like the Laws of Homoeopathy, the logic in theory might make sense to some, but is mostly theoretically based, and any scientific observations made in an attempt to prove this philosophy is not theoretical, are themselves subjective in nature (recall the “paradigm argument” for scientific observations: one scientist sees evidence supporting the wave theory for light, his comrade then viewing the same observation see evidence for the particle theory of light).   But notice how the above syndrome has several possible names and lines of reasoning for its ocurrance–be it Brugada Syndrome, SUNDS, or some other form of ARVC depends in part on the ECG interpretation, and the emphasis the physicians adhering to this diagnostic process place on the psychological components relative to the somatic components (the mind-body effect).

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In the United States, anorexia nervosa is very much a culturally-bound syndrome, with potential for impacting other ethnic settings in other countries in part as a consquence of learned human behavior, but also as a consequence of the sociological reasons for its development.   A study by Keel and Klump (2003) identified bulemia nervosa as culturally bound as anorexia nervosa as not culturally bound, based upon their presence in non-Western cultures.   The additional step needed to be bulimic (self-induced emesis) and the long term consequences of continued emesis as additions to anorexia nervosa effects made bulimia more detrimental to the physical body, with possible underlying mental and psychological causes further enabling this mostly single-gendered medical event from recurring.

The age-gender distribution of anorexia nervosa when compared with bulimia demonstrates a very narrow range for prevalence.  The peak age for this distribution is between 16 and 20 years of age.  This age peak is also seen for bulimia, but the distribution of cases for bulimia shows that this diagnosis continues well into the early adult years.   The cultural link for this disease is a culturally-bound feature that persists into early adult years, leading to the bulimic activities related to this diagnosis.  The ecological existentialist interpretation of this behavioral outcome might suggest that the anorexia is a common cross-cultural feature due to shared physiological, sociological and psychological/neuropsychological stimuli.  People behave the same during these years of life, with gender related behavioral differences also notable, although perhaps more efficiently within the western cultural setting than in other non-western countries.  When it comes to taking the next step in this biological-behavioral disease related paradigm, behaviors take over with bulimia, thereby resulting is more aggressive behaviors in older, more persistent female populations.  Thus the asymmetry in gender distributions noted above.

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Several culturally-bound syndromes exist due to the philosophy in practice at the time.  A number of hispanic or Central American illnesses fit this paradigm as well as several of Oriental origins.  Each of these two cultural settings have a medical history and philosophy that still dominated the contemporary popular cultural interpretation of health, wellness and how to treat and prevent certain illnesses from developing.

The hispanic population in the United States has several culturally-bound syndromes which seemed to recur in local news during the past few years.  Many of these illnesses are derived from three different parts of the Middle American- or Mexican-Hispanic or -Indigenous life styles and sociocultural histories.   Indigenous populations related to Aztec, Mayan, Toltec, Andean and Peruvian history tend to give rise to syndromes related more to metaphysical beliefs, with the ailments or disorders tending to be related to religious philosophy and socioculturally derived fears and concerns.  Susto is perhaps the most common of these.  The Hispanic cultural base allows for several natural philosophy derived cultural syndromes to develop, the most sommon of which is the belief in cold, air, or heat playing a major role in some psychosomatic or psychologically induced physical body manifestation or perception of the condition.  The most common example of this is a “cold air” induced ailment.

For oriental medicine, in the case of semen loss, there is a knowledge based that has a long history for the condition that is diagnosed.  In western medical teachings, semen loss is interpreted as a biological event with physical and emotional causes, either f these two categories in turn having numerous underlying reasons for the development of this state.  In eastern medical teachings, many of the western medical claims might be present in modern day health care systems, but there is an additional metaphysical philosophy based reason for “semen loss”, which due to the underlying nature of this philosophy is absent from the western medical paradigm, has some physiological and neurochemical undertones in western traditions that could be transferred over into the oriental traditional system, but in general otherwise lacks the  theoretical nature or paradigm upon which this oriental culturally-bound diagnosis exists.  Western medicine might apply this condition to the western paradigms for such ICDs as impotence or psychologically-based behavioral conditions.

Other possible cultural syndromes exist in contemporary western medicine.  We have already seen some evidence for this with the study of anorexia nervosa and bulemia.

Differentiating the cultural cause or relation of a medical condition from its physiological, anatomical cause is an increasingly difficult task due to the minutia of detail current medicine has gathered about the human body.  This seems very much a replay at times of the old adage I note elsewhere with regard to plant medicine.

Other Notes:

Example of Survey used to evaluate CAM in the US:

ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Survey_Questionnaires/NHIS/2012/English