Malaria in Africa, and in particular, Tanzania

Malaria, a disease that has been mentioned several times throughout this course, can be effectively cured by medication, but it still remains prevalent in Sub-Saharan Africa, where it kills 3,000 African children a day.  This parasitic disease is transmitted by mosquitoes. Once inside the body, the parasite destroys red blood cells and can clog cerebral arteries.  Without treatment, the initial flu-like symptoms from infection can progress to life-threatening illness.

Malaria is a major public health issue in the poor countries of Africa, where it is tied to poverty in a grim cycle: the disease is a consequence of poverty, and at the same time further impoverishes the communities it affects.  By preventing infected people from working, causing immeasurable human suffering from the loss of loved ones, leaving children with lasting neurological damage, requiring costly medication, and negatively impacting the economic decisions of households and entire nations, malaria has a devastating effect wherever it strikes.  The governments of the countries where malaria has a high incidence are generally poor to begin with, and this lack of funding for treatment and prevention is a major barrier to controlling the disease.  People with HIV or AIDS, which are also a major health concern in Africa, are particularly vulnerable to malaria.  As malaria is such a large-scale global health problem, multiple health organizations like WHO and the World Bank, as well as the UN, donor governments, and various charitable organizations are focused on addressing it.

One medical anthropologist studying malaria in Africa is Dr. Vinay Kamat, a professor at the University of British Columbia who has focused his research on how recent changes in malaria medication and control strategies are affecting those afflicted with the disease.  In a 2009 study, he researched how the Tanzanian government implemented new treatment guidelines that included the large-scale deployment of an artemether/lumefantrine-based combination therapy (ACT) medication commonly known as ALu.  This medication is regarded as an effective treatment and a “key weapon” against malaria, but its high cost is unsustainable in the long-term for Tanzania without a significant donor.  Dr. Kamat studied the public’s perspective on ALu as public health facilities began distributing it within the new policy.  He found that the majority of mothers of children with malaria do not rush to the hospital within the initial onset of the disease; rather they rely on store-bought fever medications.  Despite this, once at a health care facility, the mothers were satisfied with the efficacy of ALu, as well as its affordability due to the government subsidy.  This study prompted further questioning of how to encourage early treatment of malaria, to avoid the delay between the onset of symptoms and proper treatment.

Sources:

Bio of Vinay Kamat: http://www.anth.ubc.ca/people/anthropology-faculty/vinay-kamat.html

Kamat’s study in Tanzania: http://www.malariajournal.com/content/9/1/61

Basic facts on malaria: http://www.who.int/malaria/en/

http://www.earth.columbia.edu/articles/view/41

 

 

Clinical Medical Anthropology

The application of medical anthropology to a clinical setting is relevant to me and my goal of becoming a primary care physician.  Medical workers who strive to understand the cultures of the biomedical health system and the individual patients it serves can use this context to provide the most effective healing.  Acknowledging the unique ways in which patients view their health and their lifestyle can help avoid miscommunication and non-compliance, both of which can interfere with treatment.

Even seemingly small issues, like putting medical terminology into lay terms that are more comprehensible or emotionally acceptable for patients, can make a big difference.  For example, the Anthropology in the Clinic article we read this week explained a case study where a young Chinese woman felt alienated by the American medical system when she was diagnosed with a depressive, anxiety disorder.  Mental illness was very stigmatized within her family, and the terminology her doctors used in her diagnosis and treatment made her uncomfortable.  After her doctors were able to understand this, they were better able to communicate with her without using the Western, biomedical terminology that made it difficult for her to accept her condition.

That same article made a powerful case for doctors educating themselves to develop an anthropological background, rather than falling into the current trend of gaining “cultural competency.”  This practice of describing cultural sensitivity as a technical skill that can then be applied to patient cases is often ridden with stereotypes and builds the false expectation that addressing cultural factors can single-handedly solve clinical problems.  Instead, clinicians should train in the principles of ethnography, a much more relevant practice of engaging individuals to empathize with their personal values and viewpoints.  Through this, doctors can strengthen their interpersonal skills to reach out to patients and find out how they experience an illness, what matters most to them, and what stresses weigh down on them.  This can complement doctors’ biomedical training, which can lead to an unintended superior attitude that places technical knowledge above the actual human experience of health and disease.  In a health care system that prides itself on objective and scientific treatment, medical workers need to focus on each patient as a person with individual thoughts, beliefs, and cultural practices.  A healthy doctor-patient relationship with mutual trust and respect can then lead to the truly best healthcare.

Information from: Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It, Arthur Kleinman and Peter Benson

Medicalization of Depression

While I recognize depression as a serious illness that can be effectively relieved by treatment, I think the American culture is increasingly biomedicalizing it.  The recent upsurge in cases of depression is not necessarily from a higher rate of the disorder, but rather a higher rate of its diagnosis.  The current definition of clinical depression requires that a patient display at least five criteria on a list of symptoms that includes a depressed mood, insomnia, loss of interest in activities, and fatigue.  This definition does not account for the context of these symptoms, which could be a natural response to events like losing a loved one or experiencing a serious illness.  I think the biomedical movement in the U.S. has allowed for this looser interpretation of depression.  People who identify with the definition of depression can now take advantage of medical innovation and seek treatment.  As the Conrad article on ADHD explained, Americans who have lost tolerance for mild symptoms can now seek out a diagnosis that legitimizes their suffering and makes it easier to understand.  Allan Horwitz and Jerome Wakefield, the authors of a book entitled The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Illness, explain this biomedicalization of depression as a result of several causes: efforts to standardize the diagnosis of the condition by revising its criteria, pharmaceutical companies finding a wider base for their market, and depressed people themselves, looking for an answer in a diagnosis.

I analyzed an advertisement for Zoloft, a popular antidepressant.  This brand is known for its characteristic ads that use cartoon, anthropomorphic blobs to represent people with depression.  I think using the blobs rather than live actors influences viewers to identify with the explained symptoms, rather than an arbitrary image of what depression looks like.  In this commercial, a lone blob wallows in a dark cave while a voiceover explains the symptoms of depression: feeling alone, anxious, and tired, and not enjoying once-loved activities.  This underscores our cultural view that depression is an unnatural condition that separates sufferers from the rest of society.  The biological mechanism of the medication is explained very generally while a cartoon image shows a simplistic animation of neurotransmitters.  Like most pharmaceutical ads, this one explains the side effects of Zoloft at the end, when the depressed blob finally makes it out of his cave and joins others with a smile.  The ad tells the viewer that depression must be diagnosed by a doctor, but its ending tagline—“When you know more about what’s wrong, you can help make it right”—reflects biomedicalization’s principle that people can play an important role in their own diagnosis and treatment.

Zoloft ad: http://www.youtube.com/watch?v=QIFnHfdgXaA&feature=relmfu

Article on Horwitz and Wakefield: http://www.scientificamerican.com/article.cfm?id=really-an-epidemic-of-depression

Healthy/Sick

The term “culture of biomedicine” reminds us that while biomedicine positions itself as a purely objective and scientific form of healthcare, it still has culture and ritual of its own.  For example, the education and training of biomedical doctors is a rite of passage, and we can examine how it follows a clear progression from ceremonious events of separation from society, transition, and finally, incorporation as new members of society.  Like this week’s Quebbeman article explained, some traditions in Western operating rooms have little scientific basis.  Standard precautions like wearing surgical masks and booties to cover shoes are revered as ensuring the lowest risk of infection, but research has shown that not wearing these protective garments has no significant influence on infection rates in surgical patients.  Instead, rituals like this are steeped in the history of surgery and have remained purely out of tradition.  Recognizing cultural aspects of biomedicine is crucial to evaluating the cost-effectiveness and success of our health care system.

The Western dichotomy between “healthy” and “sick” can often be an arbitrary division on what I consider to be a spectrum between the two states of being.  This is especially true for cases of psychological illness.  Our biomedical health system changes the definitions of psychiatric conditions to reflect current ideologies within society, rather than new scientific discoveries.  Despite this subjective process, the Diagnostic and Statistical Manual (DMV) neatly categorizes over 400 mental illnesses, so that the diagnoses of these have a seemingly logical and scientific basis.  My concept of sickness is a pathological or chronic condition that impairs the body and/or mind’s ability to function.  (For this blog post, I’m not going to get into the “body” and “mind” dichotomy!)  I think that every person has the power to determine whether or not she is sick, and that a personal claim to illness legitimizes it.  Health is when the body and mind are working efficiently and are sufficiently nurtured, but I also see it as a state without disease, or without disease taking a toll on one’s life.  For instance, someone with diabetes who controls his condition with insulin might not define himself as sick.  I think the dichotomy between health and illness is so starkly defined because of our medical system, where doctors have the ultimate authority of classing each patient as sick or healthy.  Thus, the sensations of sickness are not legitimized without a diagnosis.  In a society that prizes the restitution experience of illness, where a condition is diagnosed, then properly treated and cured, we accept and deepen the line between “healthy” and “sick”.

True Life: ‘I Have NF’

This episode followed three teenagers who have neurofibromytosis (NF), a genetic condition that causes painful tumors to grow throughout the body.  Each teen has a different experience with the illness: Philip has large facial tumors that disfigure him and impair his hearing and sight, Amber has particularly large tumors around her hips and leg, and Beckha has tumors in her spine and brain that make walking extremely difficult.  For the most part, all three stories follow the chaos narrative form, since NF is an incurable condition.  Beckha’s narrative is the strongest example of chaos form.  Unlike the other two, she has no other family members with NF and therefore feels more isolated.  She has battled against the disease for years with multiple surgeries on her spine and brain, but still has severe pain and trouble walking, which is extremely frustrating for her.  Philip also tells a chaos narrative, explaining the social ridicule he gets because of his disfigurement.  This particular problem is permanent, since his doctor explains that the facial tumor is too complex to surgically remove.  While Amber also knows that her condition will last all her life, part of her story follows a restitution narrative.  A plastic surgeon is able to remove a 3 pound tumor from her side, and though it doesn’t cure her condition, Amber sees this as a huge success.

All of these teens are embarrassed by their abnormal appearances in a culture that places a high value on looks.  However, for diseases like NF that stem from genetic mutations, our society does not stigmatize the sufferers for contributing to their own disease by personal fault.  All of the medical professionals who worked with the kids offered compassionate care, exploring treatment options and discussing them with the families to find the best route for improvement.

By acknowledging their illness, seeking help from doctors, and being excused from some school responsibilities because of time off for surgeries or learning disabilities, all three teens have taken on the sick role.

Sharing their narratives with the True Life TV show might empower them by showing a large audience what obstacles they face.  Ongoing conversations about their illness with family and friends maintain a social support system.  Openly discussing their symptoms and experience with doctors ensures their best medical treatment.  For these reasons, narratives are an important part of coping with and fighting against an illness.

Fibromyalgia

Fibromyalgia is a condition that causes chronic pain in muscular and skeletal tissue, as well as a host of other physical and mental symptoms, such as fatigue, irritable bowel syndrome, anxiety, depression, and impaired memory.  Although the mechanisms of the syndrome and its effects are still unknown, scientists think that the brains of people with fibromyalgia are hypersensitive to pain because of abnormally high levels of certain neurotransmitters associated with pain signals.

Despite how severe or debilitating the symptoms of fibromyalgia may be, people suffering from it face several challenges in legitimizing the condition to friends and families, medical professionals, and themselves.  Since no definitive test exists for fibromyalgia, the diagnosis is primarily based on two criteria: widespread pain for three months, and ruling out other underlying conditions that could be causing the symptoms.  With neither a specific biomarker to prove this condition or visible signs of illness, patients might feel self-conscious communicating their complaints to others, afraid that they’re not being taken seriously.  Many women with chronic pain conditions like fibromyalgia report that the ambiguity of their syndromes can make them blame themselves for their painful symptoms, and separate them from their self-identity of being a strong individual.  I think that our society’s reliance on biomedicine as healthcare demeans the suffering of people with conditions that aren’t fully explained through biology.

Our healthcare system has developed to treat specific diseases and injuries, but is less effective at treating a patient as a whole person.  Since fibromyalgia is an incurable syndrome, treatment plans focus on managing its symptoms.  Western doctors can prescribe pain medications, antidepressants, and sleeping aids, but these drugs only partially treat fibromyalgia.  People with the condition also benefit from adapting their lifestyle to reduce stress, get adequate sleep and exercise, and eat nutritiously.  Many seek and gain relief from alternative forms of healing, like acupuncture and massage.  Counseling and social support are crucial to helping someone mentally cope with the illness.

Belief is an important part of healing.  As the video “Placebo: Cracking the Code” explained, the level of faith people place in health professionals and medications is a strong determinant of the level of healing they experience.  In the placebo effect, this faith itself is able to alleviate pain and sometimes even cure illness.  I myself probably experienced this during my childhood when I was sick and stayed home under the care of my mom.  Because of my belief in her ability to make me feel better, drinking ginger ale and eating saltines under her direction could sooth my nausea, even if these foods themselves had little physical effect.  In the video, a surgeon in Houston found that simply going through the ritual of knee surgery without actually performing the surgery could completely heal patients who previously had debilitating knee pain.  The patients experienced this healing purely because they expected to.  Research like this opens up the potential of harnessing the body’s ability to heal itself by relying on the mind and its beliefs.

Information from:

http://www.mayoclinic.com/health/fibromyalgia/DS00079/

Werner, A., Isaksen, L., & Malterud, K. (2004). ‘I am not the kind of woman who complains of everything’: Illness stories on self and shame in women with chronic pain. Social Science & Medicine, 59, 1035–1045.

Zar in Africa and the Middle East

Zar is a culture bound syndrome of spirit possession that leads to disease in its hosts.  It occurs in countries throughout the Middle East and Northeast Africa, primarily affecting middle-aged women.  The term zar refers to not only the illness, but also to the healing rituals that treat it by pacifying the intruding spirits.  These spirits cover a spectrum of individual entities that constantly expands to include characters from current culture.  These include religious and political figures, and each have their own personality and whims.  Physical symptoms of zar include headaches, chest pain, anorexia, gastrointestinal disorders, fatigue, body aches, and fear.  Zar is most common among women who are infertile, divorced, unhappily married, unemployed, or with a family history of the condition.  Considering these life situations as risk factors, I think zar typically affects women who feel anxious and vulnerable from their life situations.  Women without a position in a stable family structure, or with a low quality of life because of poverty, are more apt to develop mood disorders like zar.  The way zar victims feel split between themselves and an intruding spirit resembles what the Western world calls multiple identity disorder.

Most people who experience the symptoms of this disease first seek treatment by Western physicians and traditional healers, who comprise the professional and folk sectors of healthcare.  If this treatment proves unsuccessful, the client will then turn to zar practitioners called shaykhas, who occupy a specific niche of the folk sector.  After diagnosing the condition, the shaykha conducts an inception ceremony, a week-long celebration with singing, dancing and feasting, that symbolizes a wedding for the client, the “bride” of zar.  This culminates in the client going into a trance and the shaykha negotiating with the spirit.  The end result of this treatment is a liberation from the negative symptoms of zar, but not from the spirit possession itself.  The client will continue to live as a host of the spirit, obligated to comply with that spirit’s demands. In an objective view of this therapy, the client benefits from the social support in the ceremony.  The resulting feeling of involvement and sense of belonging may help alleviate the causes that initially led to the sensation of spirit possession.

This information came from an article written by Sheikh Idris Rahim and printed in  pp. 146-147 of Encyclopedia of Multicultural Psychology, which can be accessed online through the following link:http://books.google.com/books?id=_hcurFqnQioC&pg=PA146&lpg=PA146&dq=culture+bound+syndrome+zar&source=bl&ots=YSf83jYVul&sig=rL2yZR9sQwwW__A_AMK4QKP82TQ&hl=en&sa=X&ei=dAMKUIqVNYi3qAGM4ezACg&ved=0CE8Q6AEwAQ#v=onepage&q=culture%20bound%20syndrome%20zar&f=false

 

Clown Doctors in NYC

Across New York City, a troupe of clowns has made it their mission to bring their antics to the pediatric units of hospitals, where they entertain children and their families.  Their presence lightens the atmosphere of the hospital, making it a happier environment for the kids, their families, and the medical providers.  This article points out the numerous parallels between these clowns and the shamanistic healers of other cultures.  For instance, like many shamans, the clowns frequently perform magic tricks for their audiences.  This sleight of hand made spectators trust in the power of their spiritual healers; for the clown doctors, these magic tricks can either serve to captivate the children’s attention, or to build the confidence of children who see past the thinly veiled tricks.  While the hospital atmosphere can make a child feel powerless, calling the bluff of a clown, or just laughing at his goofiness, can make a child feel in control of her situation.  The wild clothing and make-up of the clowns is also similar to what traditional shamans wore.  Both this and the characteristic odd behavior of clowns and shamans has allowed both to break the cultural expectations of their society.  Ultimately, these clowns brighten the spirits of kids—allowing them to accept their situation and comply with treatment—as well as the spirits of medical workers, who may otherwise be fatigued from the bleak situations they see everyday.  In this way, the clowns represent how blending elements of traditional healing with the Western medical system can lead to optimum outcomes.

Clowns are a traditional character in American society, as well as in many other cultures.  Their society status is that of a bizarre, but staple, entertainer.  While they are rarely respected as healers of any sort, a clown in performance has the power to manipulate his audience, and has a unique ability to completely break the rules of his society.  The NYC clowns interact with their audience through music, magic tricks, puppetry, and jokes, all in an effort to create humor and distraction, and lightheartedly poke fun at the medical system, which can often seem intimidating to children.  While clowns are anything but conventional, they do this work in conjunction with an established hospital system.  These hospitals primarily operate through biomedical diagnosis and treatment, which requires licensed health professionals to define each disease through its biological symptoms and prescribe clinically proven treatment.  The clowns’ healing powers are not an alternative to this, but instead, an addition to it.

When the Bough Breaks

I got a 4 out of 10 on the Health Equity Quiz.  The answers to these questions were really eye-opening, both about the success of the U.S. medical system compared to other countries, as well as about how much wealth and social class determine health.  Considering how much we Americans invest in our healthcare, I had expected us to be better than 29th in the world in terms of longevity!  I was also surprised by how much the health of individuals in the U.S. depends on class level, versus other factors like smoking or exercise.

When the Bough Breaks documents how the effect of racism against African Americans—which many Caucasians think is a thing of the past—is still powerful enough to severely increase the rate of premature births for African American mothers.  Even correcting for education and wealth, which usually predict the health of newborns, African American women are three times more likely than white women to birth premature or underweight babies.  Researchers have shown that this risk is not due to any genetic basis from African heritage.  In fact, the rates of premature birth rates in African immigrants to the U.S. are equal to those of white Americans.  This trend stops after the first generation of immigrants, however.  After that, the immigrants’ future generations suffer from the same high risk of underweight babies as African Americans.

This prompted researchers to consider how the chronic stress of racism across a woman’s life might impact her pregnancy.  Since stress hormones play a natural role in triggering labor, women with constantly high levels of these hormones are more likely to go into early labor.  Stress can also limit bloodflow to the placenta and cause inflammation inside the uterus, both limiting fetal growth and prompting premature delivery.

Social structures like racism, as well as economic, environmental, and political forces can contribute to the health of individuals.  While I generally focus on the biological and lifestyle factors that influence health, these other aspects can be very important.  For example, political action and the environment both influenced the spread of disease in North Africa when government initiatives built dams on the Nile River.  Bringing water sources close to new populations increased the prevalence of a parasitic disease called schistosomiasis, which thrives in water snails.  The culture of these affected areas determines who develops the disease, and how it has progressed.  Since many women in this area are Muslim and do not swim, the disease mostly afflicts fishermen and young boys.  Since a symptom of the disease, blood in the urine, is interpreted as a rite of passage for boys, few of the afflicted individuals recognize it as a sign of illness and seek treatment.

Celiac Disease in Caucasian Americans

Celiac disease (CD) is a chronic intolerance to gluten, the protein found in wheat, barley, and rye.  When gluten enters the digestive tract of someone with CD, it triggers an autoimmune attack, and the resulting inflammation destroys the villi of the intestines.  Without these finger-like projections of the intestinal surface, normal nutrient absorption can’t take place and serious digestive symptoms result.

Nearly every article about celiac disease states that the condition is most frequent in people of Northern European descent.  Despite this consensus, I was hard-pressed to find a chart or set of statistics that directly compare the prevalence by racial groups, so the above graph is the best I could find.  It at least shows that the rate of celiac disease in African, Hispanic, and Asian-Americans is lower than the rate of the general population, which factors in Caucasian Americans.

One of the highest risk factors for celiac disease (CD) is a family history of the condition.  Nearly every patient diagnosed with CD has a specific form of the HLA genotype that is associated with causing the disease in conjunction with environmental factors.  Since the main gene pool of people with this mutation originated in Northern Europe, all of their descendents throughout North America, Australia, South Africa, etc. are at a higher risk for inheriting this genetic predisposition to the disease.

The medical community agrees that celiac disease is generally underdiagnosed, Another possible reason minorities have a lower prevalence of CD is that in some communities, they are less likely to have access to health care, and are less likely to undergo the intestinal biopsy that leads to a CD diagnosis.  Because of this, reported diagnoses of CD in minorities might not fully represent the true number of cases.  The processing of wheat and bread are also linked to the incidence of celiac disease, which has multiplied by four times in the past 50 years.  Certain ethnicities may not include as many wheat products in their diet as Caucasians, leading to a lower incidence of gluten intolerance.

This week’s materials helped me separate the concepts of race and genetics.  I learned that race is a socially-constructed idea that can only be determined by self-identification.  Scientists agree that race has no genetic basis.  This means that no genetic test or biological examination could distinguish one race from another.

Genetics, on the other hand, is comprised of the concrete structures of DNA that impact how the body functions.  Specific genotypes can be linked to disease, either as a direct cause of some malfunction, or as a risk factor that can predispose someone to developing a disease.

The line between genetics and race can sometimes be blurred when studying their impact on health.  For example, in the Pima Indians in the U.S. have a severely high incidence of Type II diabetes.  This is due to a specific gene preserved in their population because it once gave them a survival advantage to store energy during famines.  However, the gene has been limited to their specific ethnic group since for the most part it has not been passed on to generations outside of the Pima population.

Works cited:

http://news.medill.northwestern.edu/chicago/news.aspx?id=150813 (for information and graph)

http://emedicine.medscape.com/article/171805-overview#a0101

http://voices.washingtonpost.com/checkup/2009/07/celiac_disease_increases_sharp.html