Abstract and Notes: Relationships between Theoretical and Applied and Anthropology: A Public Health Analysis, George M Foster

Posted on September 18, 2011 by

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Abstracted by Brian J. Delas Armas

Foster’s article represents an attempt to justify the work of applied Anthropology in the context of the 1950s.  He says that the ambivalence towards engaging in Applied Anthro was premised on the compromise of the scientific integrity of their work.  Attempting to assert the scientific applicability of the discipline, he framed the findings in terms of aiding the administration of biomedical science to individuals in Latin American countries.  He aimed to do this by saying that what they found could be immediately applied to programs, and that their contributions would sharpen anthropological theory to the point where they could make predictions and produce general guides for how medical practicioners could act.

To do this research, he and a team of Anthropologists studied health centers, which focused on preventative medicine for children and mothers.  Seven countries in Latin America (Brazil, Colombia, Peru, Mexico, Chile, Ecuador, El Salvador) each had two health centers that were the loci of foci of the study.  One health center would be located in an urban setting, another in a rural area.

Research methods consisted of observations of doctors and nurses, health education classes, and general operations, and the reactions of patients.  They did random door-to-door of patients sampling.  They gave tests to nurses to test out if they still held “erroneous” beliefs.  The data the researchers produced was the beliefs and attitudes held by patients, potential and former, and the types of illnesses in which they consulted doctors or curers.  The study period spanned a period from 1951-1952.

The main theoretical contribution of Wallace’s article was the highlighting of the significance of patient beliefs and their own practices of healing.  These patient beliefs and practices strongly influenced their attitudes and behaviors towards public health centers and subsequently helped influence their health outcomes.

Foster also showed the need for cultural relativism;  he showed that what practice might work in one context for one group may not work for another group of people.  He noted that a team of El Salvadorean doctors and nurses trained in the US had learned a US-based practice: that babies would be best weaned every 3 hours.  This went against Latin American belief, but was taken by doctors and nurses as truth. If something went wrong with the baby, it was the fault of parents who did not wean their child every 3 hours.  Ironically, the US-based practice was disregarded by the time the article was written.

Foster described a few of the Latin American beliefs in healing under the heading of “the nature of folk medicine.”  He noted that the beliefs were rational or made sense according to their own premises.  For example, central heating was considered un-hygenic and even dangerous.  This belief stemmed from the idea that if you breathe air much colder than the moment before, you’re likely to contract an illness called “aire.” The moment you stepped out of the centrally-heated house, therefore, made you susceptible to illness.

Most common diseases were the same as found in biomedical medicine.  However, there were causes considered supernatural if outside the realm of verifiable causes.  He found that people’s own description of the symptoms of diseases were broad and vague.  For Wallace, the broad descriptions of these symptoms, made the people susceptible to self-fulfilling prophecies that they were afflicted by a certain illness, and thus making them seek out a native healer or curandero.  Additionally, they found that many patients could talk about home remedies that they themselves applied and used.  He found that their beliefs and practices in health were not something that could be dismissed, but were deeply embedded in their way of life.

Foster found that patient utilization of the public health centers may have been limited for a host of reasons including: those aforementioned beliefs and what Wallace called “the weight of folk tradition”, the rudeness displayed by doctors and nurses, the bureaucracy of the centers preventing the treatment of children, the bad hearsay generated from those doctor-patient interactions, the incompatibility of hours, the focus on preventative rather than curative medicine.

To address these barriers, he suggested a bevy of solutions premised on doctors and nurses accepting and working with the patient population’s beliefs.  For example, a patient might say they have a “dirty stomach.”  Rather than dismissing the idea of a “dirty stomach”, the doctor would prescribe the same medicine and tell the patient that the medicine would cure “dirty stomach.”  He further suggested that curative medicine become a focal point for attracting more patients so that they may eventually participate in the practice of preventative medicine.

Notes

  • Describing the feeling towards applied Anthro in the 1950s:  Ambivalent towards applied anthro because on one hand they should do more than just theorize, but on the other, they don’t want to corrupt their “scientific integrity”
  • Goals and values of Anthropology in the 1950s:  traditionally stressed research.  Scientific progress would be made if committed to science.   This assumes that evolution towards something better is natural.
  • But the article sees that the achievement of progress would revolve around a combination of human knowledge.  As an example, the size and scope of technical aid programs or Point IV will also revolve around this combination of human knowledge.  Anthros have a ‘responsibility’ based on knowledge, working techniques, and concepts
  • Paper’s goal:  bridge the gap between theoretical and applied points of view.  They want to find the regularities in cultural processes which would facilitate the development of concepts and operational procedures to be used/imported into other contexts.  Ultimate success of technical aid program depends on ability to predict how people will react to them, and how human element, is manipulated to achieve a particular goal.
  • Research Setting:  Health centers, which provide pre-post natal hygiene, infant hygiene, dental clinic, communicable disease control, lab analysis, enviro sanitation, home visits — maternal and child health.  Health center work is considered “preventative”
  • Methods:  Two periods in the 1951 and 1952 in two Health centers each in Brazil, Colombia, Peru, Mexico selected.  One in urban area, one in rural area.  Chile, Ecuador, El Salvador later added in 1952.  Health center personnel include directors and inspectors are interviewed.  Doctors and nurses are observed in action.  Home nurses are accompanied in rounds.  Random sampling done door-to-door.  Operations of servicio hospitals, health education classes studied.  Gave tests to nursing students to see what “erroneous” beliefs they still held.

Assured that cultural anthropologists were familiar with “general outlines” of the culture, and they used “essentially” the same field techniques and methods.

  • Data is a full description of folk medicine which includes the following information:  types of illnesses that they consult doctors, those that they talk to curer, attitudes of patients, potential patients, and former patients on those centers
  • Research Problem:  “In order to work with a people, you have to understand their culture…”two conditions to their research has to be met:  1)  results must be such that they immediately see how applied to existing and practical programs  and 2)  contributions made to basic anthro theory, by testing premises or hypotheses.
  • Satisfying condition 1: Essentially, the data they get as Anthropologists, cultural data, would promote a higher degree of efficiency in the doctors’, nurses’ delivery of services.  And then you’d see better health and hygiene, higher agricultural yields, and basic education and increased literacy.  This would account for them fulfilling the first condition.
  • Satisfying condition 2:  Testing and evaluating the assumption that cultural phenomena occur in cross-cultural patterns that can be defined and analyzed vs. haphazard and unique.  If successful, they will generate general predictions to make guides for program planners and admins.
  • Limitations:  Unable to do “traditional” anthro research, defined by studying econ organization, income, cost of living, family, literacy, and so they rely on what’s in the record, but they cite:

Two categories of data important in their study

  1. Complex of beliefs, attitudes, practices associated with health prevention, disease, and curing:  folk medicine
  2. Analyzes patient reaction and noting attitudes when they come to public health setting

The Nature of Folk Medicine

  • In Latin America, there’s a belief in balances and humors, which was derived from Spanish and Portugese who derived them from Hippocrates and Galen.  Proper balance of four humors means you’re healthy;  imbalance produces illness.  There is a widespread tendency to explain illnesses in terms of “hot” and “cold” as if they are innate qualities of substances.
  • Example of how belief is rational on their premises:  Abnormal cold causes respiratory illness.  Bad air causes illness.  Getting “aire” or mal aire is inevitable if you emerge from a house when warm.  This also explains the belief that central heating is unhygenic.  Also in this category:  Bad odors (Colombia), empacho (Chile)
  • Most common natural diseases have names corresponding to natural medicine.  They have whooping cough, colds, grippe, appendicitis, diptheria, measles, chickenpox, smallpox, intestinal worms, venereal disease, typhoid fever, pneumonia, tuberculosis, etc.
  • Other causes can be called supernatural if they are outside verifiable causes.  Mal de ojo is the most widespread illness in Latin America.  Some people have ability to cause sickness in small children just by looking at them.  Sometimes susto or fright is magical in origin because a malignant spirit takes possession of an individual.  Examples:  voodoo dolls, belief that cold essence emanates from corpse causes bystanders to fall ill unless the corpse is ceremonially bathed or washed.  El Salvador (bijillo), Colombia (hielo de muerto)
  • Emotional experiences can cause people to fall ill.  Susto or espanto results from fright;  it’s explained as a shock that separates the spirit from the body.  Colerina is disturbances from range.  Desires are antojos;  unfulfilled food desires of pregnant women results in birthmarks, those of small children give them gastric upsets;  in Chile, they never refuse children food.  Sibling rivalry is recognized in the form of resentment to unborn child of mother.  Sipe (Mexico), the child esta peche, in Ecuador paslon results and accompanies weaning.  Embarrassment produces chacaque (Peru), and in El Salvador it creates a sty known as pispelo.  Tiricia (Peru) results from strong disillusion.  Mal de corazon (Ecuador) results from saddening experience.
  • Symptoms are described as “generally broad and vague”:  vomitting, fever, diarrhea, sore threat, aches
  • When symptoms appear, they question experiences before.  Hypothetical example: If child has fever and diarrhea, parents ask if child fell from bed and cried.  The fall frightens the child, and gives him susto.  The vague symptoms confirm the diagnosis.  The parents become sure, and then call in the curandero.
  • Folk cures use a variety of techniques.  Herb teas are the most common, massages are most often resorted to.  For a child with evil eye, they do egg-rubbing.  Also live chicken, a pigeon (Peru & Colombia) is split open and spread all over the body.  Certain days (Tuesday & Friday in Peru) and times are used for healing.  Religious orations and creeds are recited.
  • Beliefs notable because of its pervasiveness.  It’s a way of life!  Informants talk a lot about home remedies and how their children have been afflicted by “evil eye”
  • Symptoms that have been present all the time assume a new significance after expectancy is created.  For example, someone who experiences great embarrassment may be expected to evidence a form of illness.
  • Folk practitioners named curanderos.  Midwives are called parteras, curiosas, comadronas

Problems with Public Health Centers

  1. Doctors and nurses shocking detachment and rude.  In service of trying to do a “thorough” job, they ask a lot of questions.
  2. Patients wait till they’re called.  As a result they may lose half a day of work while waiting for treatments.
  3. The center won’t treat sick un-enrolled children, which has caused antagonism in the community.

“Ways must be found to drive out characteristics of folk medicine which conflict with modern medicine.” The end goal of practitioners is to make them realize the importance of hygenic living and modern medicine

2 ways to utilize “folk knowledge” to deliver health care

  1. Frame it in way that makes it palatable for them…people accept ideas if a foreign element is made familiar to them
  2. Shows that they know and understand folk beliefs but scientific ways are better

Behind that logic, a few strategies were suggested by Anthropologists to the Institute of Inter-American Affairs

  1. Ritual numbers are interwoven, so give them prescriptions in those numbers.
  2. Find a way to deliver the placenta to the family to dispose it in traditional manner
  3. Need to give them a comfortable diet, eating what foods they want to eat
  4. Doctor needs to use their terms;  say that the medicine prescribed will help clean out a dirty stomach

Findings:

  • Complaints against the hospital are primarily belief-based.  To counter these beliefs, Wallace suggests that acceptance of the patients’ beliefs would do more to destroy “erroneous” folk belief more than educational campaign.  The failure of doctors to understand local beliefs jeopardized their programs in their respective countries.  For example, one patient remarked to a nurse that she would not go to a doctor because the doctor knew nothing about “evil eye.”
  • Suggests that there must be a lot of people who want to follow doctors orders, but they suffer the repressive weight of folk tradition.  Vaccinations are an example of people taking medications from Western medicine and that it is in demand.
  • Wallace tries to make the connection that services are in demand, but that sometimes they need to be explained to the patient population.  He gave an example of a disconnect between patients and doctors.  In a large urban center, 43% drop out of prenatal treatment vs, 21% in rural area.  Why?  Examination was a shock to allwomen because of its invasiveness, and the fact that a male doctor was doing the examination so callously and impersonally.  What could possibly account for the gap was that in the rural areas, women had nurses explain everything to them.  In the urban area, there was no one to explain anything to them!  From this, he drew the conclusion that the manner in which directions are explained was important
  • Instructions can be meaningless for people.  For example, a doctor gave instructions to a woman to nurse her infant every three hours.  However, it was useless because the woman had no clock.  Solution?  Work with local adaptations of time:  factory whistles, municipal sirens, church bells.
  • Hours and practices can also be a barrier for people.  In Latin America, gov hours are from 8a-2p.  Doctors put in only an hour or two hours at the clinics.  Periodic visits make no sense to patients;  they feel like they’re doing the health center a favor.
  • The way people take a dump was also noted as a way to show how cultural difference leads to services and technologies provided by powers will not be used.  After earthquake in El Salvador, new privies were built but not used.  They found out that they liked the outdoor atmosphere.  So they moved the privies in the bushes in the shade of trees.  However, in Colombia, privies might satisfy all the cultural requirements, but they aren’t accepted because they believe bad odors contribute to illness.
  • He notes the reality that health centers are focused on preventative rather than curative medicine.  Wallace suggests that better conditions will come through education and persuasion that recognizes the sick individual as a target to treat.  The average Latin American wants the doctor because they can cure his ills!  Curative medicine is the only way to show that a doctor knows what he is doing.  Otherwise they’ll keep telling stories of curanderos healing and doctors messing up.
  • Foster’s Hypothesis: Curative medicine must be part of public health program and relationships will be good
  • Foster emphasizes that health and sanitation are not separate parts of life.  There was a tendency amongst grassroots organizations to plan programs as isolated units.  Keystone of enviro sanitation campaign consisted of a privy campaign.  They built it, but less than half the slabs had been used.  What was wrong?  Highly unstable social organization.  Inhabitants lived there 5 years or less.  No attachment to the community.  Low income.  Cost to build privy is 10 dollars, but houses are $18-35 dollars.  Families won’t make that investment to build them.
  • Foster emphasizes need for cultural relativism:  North Americans think that what works for them, works for everyone else.  For example, visiting public nurses in El Salvador encourage mom to nurse infant every 3 hours — result of training from US – unfavorable results in El Salvador.  Now doctors say that a child should be fed when s/he wants to be fed.