17.4 Applied Medical Anthropology

Evolutionary Medicine and Health

A final theoretical approach to medical anthropology, emerging from biological anthropology, is evolutionary medicine. Evolutionary medicine sits at the intersection of evolutionary biology and human health, using the framework of evolution and evolutionary theory to understand human health. Evolutionary medicine asks why human health evolved the way it did, how environments affect health, and how we continue to affect our health through a number of factors including migration, nutrition, and epigenetics.

The story of human evolution is the story of gene flow and human migration. Each individual human carries specific gene combinations, and each human population carries with it a common set of genes. When people migrate, they bring those genes with them. If they have children, they pass those genes on in new combinations. Culture impacts population genetics in two ways: migration patterns and culturally defined rules of sexual selection impact the frequency of gene alleles, and thus genetic variation, in a human population. These genes often affect health outcomes, such as the likelihood of developing certain types of cancer or immunity to specific pathogens through exposure. The more frequently a human population interacts with other populations through migration, trade, and other forms of cultural exchange, the more likely it is that genetic material from one population will be introduced to the other. The current level of globalization makes it possible for genes to flow from one corner of the globe to another.

Moving into a new culture, whether forced or voluntary, requires adaptation. Adapting one’s culture to new rules, new norms, and new expectations, as well as adapting one’s identity to being a minority or facing oppression or prejudice, can affect the health of the migration population. An obvious example of this is the effects of slavery on Africans brought to the Americas. This impact is shown not just on their genetics, discussed elsewhere in this chapter, but also in their cultures. Syncretized religions like Haitian Vodou, Candomblé, and other African-inspired religions show the ways in which African populations adapted their beliefs to survive contact with oppression and cruelty, evolving and sanitizing certain elements while embracing others.

Populations that are physically isolated for long periods of time might experience negative effects from genetic drift as the frequency of rare alleles increases over time. Similarly, cultural groups that practice strict endogamy can experience negative effects from genetic drift. In isolation, populations can sometimes see a rise in the frequency of maladaptive gene variants, as in the case of Tay-Sachs disease found in ethnic minority populations that practice endogamy, such as Ashkenazi Jews or French Canadians. Among these populations, which have been relatively isolated from the populations around them, the genes that cause Tay-Sachs have become more common than in other populations. This suggests that isolation and segregation can result in unhealthy changes in a population’s gene pool.

Another example of evolutionary medicine is the study of the effects of the development of agriculture and the growth of urbanization on human health. The development of agriculture caused human health to change in many ways. Food became more regularly available, but diet became less varied and the amount of work required to procure the food increased. The regular movement associated with a gathering and hunting lifestyle resulted in robust overall fitness, but people were also at a greater danger of succumbing to a fatal accident before reaching the age at which they successfully reproduced. Our current lifestyle, in which many sit behind a desk for eight hours a day, five days a week, damages our spines and overall health. While food availability in Western nations is second to none, people living in those societies struggle with health problems related to being overweight and underactive. Each lifestyle has its trade-offs, and evolution has, over the past ten thousand years, affected both modern and neolithic humans differently. Through evolutionary health, we can track these changes and their adaptations.

With human migration and the concentration of human populations in urban areas, disease has grown exponentially. Pathogens can now spread like wildfire across the world. In the past, disease has had a devastating effect on human populations. As just one example, the Black Death killed over a third of Europe’s population, spreading via Silk Road merchants and the conquests of the Mongol Empire. Today we see yearly flare-ups of influenza and Ebola and are still dealing with the devastating effects of the COVID-19 pandemic that caused nations to close borders and people within nations to limit social contact with one another. Globalization not only makes it possible for pathogens and pandemics to spread, but also allows nations to cooperatively distribute vaccines and coordinate methods to contain viruses. Nations can now share medical data to help develop treatments and help one another in efforts to isolate and quarantine the sick and infected. On the other hand, international cooperation can hamper local response and prevent cities, provinces, states, and nations from acting in their own best interest.

Figure 17.12 World Health Organization (WHO) workers gear up to enter an Ebola ward in Lagos during the 2013–2016 Ebola pandemic. (Credit: Bryan Christensen/CDC Global/Wikimedia Commons, CC BY 2.0)

At the heart of each of these areas of study is epigenetics, or the change of the expression of a gene during a single human lifetime. Often prompted by environmental exposure and mutations over a lifetime, epigenetic shifts are heritable changes in a person’s DNA that are phenotypical, meaning that they are linked to outwardly expressed traits. For example, studies show that people exposed to smoking in childhood tend to be shorter in adulthood. Similarly, trauma can stunt growth or increase the likelihood of developing specific maladaptations. The development of sickle cell anemia in the African American community has been linked to epigenetic adaptation to slavery in the United States, according to a 2016 study by Juliana Lindenau et al. This and other studies suggest that trauma can be inherited and can last generations. Epigenetics show evolution at work in real time, affecting both individuals and future generations.

Culture and the Brain

The human brain is a fascinating research topic, both medically and culturally. Different cultures conceptualize the brain, its functions, and its health differently. Biomedicine and ethnomedicine systems view human physiology in distinct ways, and these two systems typically have very different explanatory models for understanding the brain and its role in psychology and neurology. Anthropologists are interested in both of these explanatory models and the ways they influence treatment. Some topics of particular interest to medical anthropologists include how psychology affects biology and health, the stigma of mental health across cultures, addiction, culture-bound syndromes, and experiences and illnesses related to stress. Daniel Lende and Greg Downey brought together these topics under the heading of neuroanthropology, an emerging specialty that examines the relationship between culture and the brain.

As highlighted during the discussion of the cultural systems model, the acceptance of psychology is highly variable by culture. Societies that rely upon biomedicine are more apt to embrace psychological approaches to mental health problems. Encouraging other cultures to apply psychology and psychiatry sometimes requires an anthropologist’s touch. One challenge for a medical anthropologist is convincing people who do not believe in mental health challenges that acknowledging and treating mental health issues is a better approach than ignoring them. India’s slow but eventual acceptance of psychology is described by Rebecca Clay in a 2002 article. In this case, psychology was gradually normalized and accepted through a combination of Indian medical theory and psychological treatments and diagnoses. This culturally based path toward normalization indicates the need for cultural understanding and a nuanced approach by medical anthropologists.

Culturally specific nuance is especially important in understanding what anthropologists call culture-bound syndromes. Culture-bound syndromes refer to unique ways in which a particular culture conceptualizes the manifestations of mental illness, whether as physical and/or social symptoms. The condition is a “cultural syndrome” in that it is not a biologically based disease identified among other populations.

A prominent example is susto, a syndrome in Latino societies of the Americas. First documented by Rubel, O’Nell, and Collado-Ardon (1991), susto is stress, panic, or fear caused by bearing witness to traumatic experiences happening to other people around you. Originating with Indigenous groups in the Americas, this panic attack–like illness was seen as a spiritual attack on people and has a number of symptoms ranging from nervousness and depression to anorexia and fever. Cultural syndromes are not limited to non-Western societies, however. According to anthropologist Caroline Giles Banks (1992), anorexia nervosa, an eating disorder where the person does not eat in order to stay thin in accordance with the beauty standards in the United States and Europe, is a prime example of a culture-bound syndrome. Only in these cultures, with specific pressures on weight and beauty applied to women and men, does anorexia nervosa appear. But as these beauty standards spread with globalization and the spread of media from these cultures, so does the disease. Cultural syndromes are not restricted to cultures that prefer biomedicine or ethnomedicine: they are as diverse as human culture itself.

A related concept gaining ground in psychology is known as cultural concepts of distress, or CCD. These concepts, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5, “refer to ways that cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions” (American Psychiatric Association 2013). In sum, CCD is used to describe how a culture explains and conceptualizes the unique manifestation of mental illness as physical and/or social symptoms.

The psychobiological dynamic of health—the measurable effect of human psychology on physical health—is a primary tool used by medical anthropologists to study health. The psychobiological dynamic of health helps anthropologists evaluate the efficacy of health-related treatments that may not accord with those used in their home culture. For example, ritual healing has real measurable effects on people, both the patient and those in attendance during the ritual, as long as they believe that the ritual has healing power. Similarly, for those who share a cultural belief in the power of such practices, being prayed over by a priest or blessed with holy water can offer effective healing power. Psychological belief grants healing efficacy. The same principle applies to biomedicine, as illustrated by the placebo/nocebo effect. Of course, belief alone cannot entirely negate the harmful or helpful effects of medicine or any other substance.

Another area in which psychology and health intersect is the experience and effects of stress, a human universal. Indeed, it is well established that mental stress can make someone physically sick. The work of anthropologist Robert Sapolsky (2004) analyzes the evolution of the human body to adapt to, use, and heal from stress. His analysis suggests that stress pushes humans to both physical and mental limits, that these limits differ in different humans, and that being pushed up against limits due to stress can result in growth. The human ability to adapt to stress is a difference from other primate species, and it likely developed over millions of years of evolution. While human bodies have evolved with stress and have sometimes grown as a result of stress, we were not evolved to withstand chronic stress over extended periods of time. Chronic stress induces a high rate of stress-related diseases, such as heart disease, indicating the limits of even evolution to adapt to long-term stressors.

Addiction is another area in which medical anthropologists have done significant work, analyzing how culture and biology contribute to addiction. Addiction comes in many forms and affects multiple measures of health. Medical anthropologist Angela Garcia tackles addiction in her book The Pastoral Clinic: Addiction and Dispossession along the Rio Grande (2010), which explores the intersection of race, class, immigration status, and dispossession with drug addiction and the ability to treat it. Focusing on a small town on the Rio Grande and specifically a clinic within that town meant to treat addiction, she tracks the trajectory of a number of patients and the factors that contributed to their addiction. Her analysis highlights the status of these patient as immigrants, minorities, and outsiders, which prevent reentry into society for many. Similarly, João Biehl’s work Vita: Life in a Zone of Social Abandonment (2103) analyzes the effects of dispossession and homelessness on social health, looking specifically at the role of drugs in the highlighted zone. His exploration of vita, a place where people are “left to die” when their addiction or mental illness becomes too much of a burden, shows the cultural effects of mental health and addiction on Brazilian society and the struggles of the individuals abandoned there. In both works, the role of drugs is highlighted, exploring how cultures symbolically characterize problematic drug use and addiction and attach a stigma to admitting a problem and seeking treatment. The works also explore how drugs are justified and understood, illustrating both how drugs change the biochemistry of the brain and how the human mind characterizes the drugs, each shaping one another.

Reproduction

Reproductive health is another area in which medical anthropologists have made significant contributions by applying their knowledge and methods to real medical practices. Medical anthropologists have studied reproduction in many cultures, analyzing the practices, beliefs, and treatment of those who are pregnant, their children, and their supporting network. Another area of interest has been the ritualization of pregnancy. Robbie Davis Floyd (2004) has done work on birth as a rite of passage and the role of the midwife in modern birth practices around the world, with a focus on medicalized birth in the United States. Her work highlights ways in which the experience of birth is made more complicated by policy. Midwives are shown to decrease the chances of complications in births, yet in many places they are denied a role in the birthing process. Regardless of patient preference and the documented success of midwives, in most settings in the United States doctors and medical professionals are given preference over midwives. Floyd argues that this preference sometimes puts the patient at risk. In the Western biomedical system, doctors are preferred and imbued with authoritative knowledge, which is a sense of legitimacy or perceived authenticity.

Figure 17.13 Women of color are much more likely to die in childbirth, according to a 2019 study by the CDC. This disparity is a central focus of the research of Dána-Ain Davis. (credit: “Figure 1: Pregnancy-Related Deaths per 100,000 Live Births by Racial/Ethnic Group, 2007-2016” by US Government Accountability Office (GAO)/flickr, Public Domain)

The work of Dána-Ain Davis (2019) on medical racism and inequalities in the health care system shows structural violence at work. Based on analysis of statistics and vivid ethnographic examples, Davis found that women of color experienced significantly higher rates of complications, including higher death rates for both mothers and infants, than White mothers and babies. Davis concludes that cultural bias and systemic racism are woven into the US health care system. These are often unacknowledged biases, unrecognized by those perpetrating them in the medical profession. Davis advocates for better policy to address these inequalities and help mothers maintain control over their bodies and the birthing process.

The Inequalities of Health

Attempting to address the inequalities of health care is a primary application of the work of critical medical anthropologists. Inequalities are apparent in relation to COVID-19, the global pandemic that has left no corner of the world untouched. A number of agencies in the United States, including the National Institutes of Health and the American Civil Liberties Union, have determined that Black and Latinx populations have been most negatively affected by the virus, both in health outcomes and overall deaths per capita relative to their portion of the population. Several states have emphasized the need to ignore personal safety for the sake of economic “health,” essentially stating a willingness to sacrifice workers so their economic prospects do not falter. Meanwhile, people working on the front lines faced what is tantamount to class violence, as they could not afford to stay safely at home and social distance; indeed, it can be argued that later this class violence still applied, as the divide between remote working and those forced to work on-site created a stark contrast. The health of “essential workers” is put at risk. Aside from health care professionals, the category frequently falls along class lines, with the majority of “essential workers” employed in the service industry, in factories, or making deliveries. Economic inequalities and lack of access to health care providers both play a role in these trends. Similarly, the World Health Organization has highlighted how poorer countries have had their access to the many forms of COVID-19 treatment and prevention restricted by the demands of richer countries like the United States and Australia.

Another area in which medical anthropologists have documented health-related inequalities in the United States is access to nutritious foods. It has been well established that poor access to foods, particularly highly nutritious, diverse foods, can negatively affect health. People who live in food deserts, which are areas lacking access to good food, are more likely to develop debilitating illnesses and suffer from a basic lack of nutrition in several major fields. Amplifying the effect of food deserts is that these same areas often also lack access to health care services.

AIDS has provided a multigenerational study of the inequalities of health. At the beginning of the AIDS pandemic in the 1980s, the poorly understood disease was stated to be a “gay man’s virus” because it seemed to only affect gay and bisexual men. Medical anthropologists began studying the AIDS virus as early as 1983, with Norman Spencer notably studying cases in San Francisco. As the virus spread to other populations, research became more common and well-funded, receiving state support in some cases. Yet between poor and late funding and the spread of misinformation that took decades to reverse, AIDS devastated populations around the world. Medical anthropologist Brodie Ramin (2007) has applied anthropological knowledge and methods to AIDS treatment in Africa, utilizing cultural understanding to develop more effective methods of medical treatment and enhance public trust in these treatment methods.

Figure 17.14 Partners in Health began treating HIV in Haiti at a time when world governments largely ignored it. Here, they offer help during the 2010 Haitian earthquake. (credit: “CG Officer works with Interpreter to Help Haitians” by Petty Officer 2nd Class Etta Smith/USCG Press/flickr, CC BY 2.0)

Even today, AIDS is highly stigmatized and poorly treated in many places in the world. For over two decades now, Paul Farmer and Jim Yong Kim, both anthropologists and medical doctors, have worked with their organization, Partners in Health, to provide better health outcomes and access to poor, remote parts of the world. Their work has been instrumental in helping treat AIDS and other diseases in places such as Haiti. Jim Yong Kim used his role in the World Bank Group to help create better outcomes as well. Medical anthropology has the power to shape policy at the highest level of global health institutions, but it has much to overcome. Medical anthropologists are well aware of the severity of the problems of structural violence, systemic racism, and massive health inequalities around the world.

The COVID-19 pandemic changed many aspects of many cultures, affecting people’s professional, educational, and personal lives. Medical anthropologists Vincanne Adams and Alex Nading have already begun to analyze the social impact of COVID-19: “The pandemic continues to precipitate simultaneous dread over what is to come and loss over what appears to be gone forever, including loved ones, ways of life, and conceptual and literal safety nets” (2020). The COVID-19 pandemic has illustrated how deeply intertwined health and culture can be. Elisa J. Sobo’s work on the anti-vaccine movement in 2016 is now freshly relevant, as some people fear and mistrust both the COVID vaccine and the health measures to slow or prevent the spread of the virus proposed by nonprofits and governments. Adams and Nading build upon Sobo’s research, exploring the central role of belief and culture in the development of policy at the local, state, national, and international levels during the COVID-19 pandemic.

The COVID-19 pandemic has illustrated how deeply intertwined health and culture can be. Medical anthropology has a lot to offer public health and health care professionals. Incorporating medical anthropology and cultural competence into the training of health care professionals is a proactive step to begin addressing medical racism and the inequalities of health documented by medical anthropologists. It also gives health care professionals insight into the relationship between social health and physical and mental health priorities. The work of medical anthropologists on nutrition, reproduction, and infectious disease has significant implications for health care and public policy. Finally, understanding the wealth of cultural traditions and ethnomedical systems provides a greater appreciation for the diverse ways of understanding health and managing maladies. As the COVID-19 pandemic has demonstrated, health and health care are a complex social issue with global ramifications for billions of people.

Resources: Explore Medical Anthropology

• Culturally Connected is an excellent educational resource for health care professionals that draws heavily on medical anthropology.
• Neuroanthropology is a collaborative weblog created to encourage an interdisciplinary exchange.
• Somatosphere is an online forum for debate and discussion in medical anthropology.
• Anthrolactology is a podcast series on anthropology, breastfeeding, science, and society.