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Medical Anthropology in Applied

Perspective

Lynn Sikkink

Lynn Sikkink, Ph.D.

Western State College

Australia Brazil Japan Korea Mexico Singapore Spain United Kingdom United States

 2009 Wadsworth, Cengage Learning

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CONTENTS
1

MEDICAL SYSTEMS

HOW MEDICAL ANTHROPOLOGISTS WORK

ILLNESS AND HEALING

Medical Practitioners

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INTRODUCTION

MEDICAL ANTHROPOLOGY & FOOD AND NUTRTITION

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Malnutrition

15

Subsistence and Nutrition Patterns

18

BIRTH AND REPRODUCTION

26

Pre-natal Care

26

Birth Practices

27

Post-partum Beliefs and Practices

27

HEALTH CARE AND CHANGE

29

SUMMARY

29

KEY WORDS/DEFINITIONS

30

QUESTIONS FOR REVIEW OR DISCUSSION

34

SUGGESTED FURTHER READING

34

RESOURCES ON THE INTERNET

35

FILM RESOURCES

35

REFERENCES CITED

35

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PREFACE

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Medical anthropology has become an ever broadening field that is both

interdisciplinary and applied. Many students of anthropology will go on to work in
this field, whether it is in health care, medical research, nutrition, the study of
traditional medicine and its applications, or child birth and development. The
topics, perspectives, and approaches developed in this field of study therefore
provide practical training for the world that students will enter.
Medical anthropology may be a career choice, but it is also a useful way of
looking at human interactions in general. Understanding the cross-cultural
variations in the way that people perceive illness and health, treat their ailments,
view the mind-body connection, and the values underpinning these perceptions
gives us a global picture of the human condition, and the world in which we live.

Lynn Sikkink

ACKNOWLEDGMENTS

I had my first chance to teach medical anthropology at San Jose State

University, and would like to thank my colleagues there for help in developing my
ideas about the topic from an applied perspective. As a graduate student I was
lucky to take a medical anthropology course from Nina Etkinappropriately, a
photo of Dr. Etkin doing research in the field is included in this module. Thank you
to Gary Ferraro for helpful comments on improving the material in this unit. I am
also extremely grateful to Lin Gaylord at Wadsworth/Cengage Learning for her
fine editorial comments, and for helping me through this process of modulewriting. Finally, I want to thank my new colleagues at Western State College for
providing the comfortable academic environment in which this work was
completed.

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INTRODUCTION

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The well-being of the human body is a topic in which all societies are
interested. Each society has a distinct way of defining and promoting good health
and curing the ailments from which people suffer. Medical anthropologists
research these cultural differences and involve themselves deeply in the crosscultural issues surrounding health, illness, and health care. As anthropologists they
bring unique perspectives and approaches to the study of health and illness because
they are experts at examining both the cultural beliefs surrounding health that
include patterns of illness and notions of the body by a particular group of people,
and practices of those who cure illness. These considerations lead medical
anthropologists to an exploration of the healers from whom people will seek help
when they are ill. Anthropologists ask questions about the role of healers in a
society; about when individuals treat themselves and when they seek help from
outside specialists; what kinds of treatments they use; and what the general cultural
context is of those beliefs and practices. This set of questions and concerns is very
anthropologicalit is holistic and oriented toward the culture itself, but it also
enables researchers to understand the various beliefs and practices as a meaningful
whole in explaining why people do what they do and what meaning this has for
them.
A good working definition of medical anthropology comes from Cecil
Helman: Medical anthropology is about how people in different cultures and
social groups explain the causes of ill health, the types of treatment they believe in,
and to whom they turn if they do get ill (Helman 1994:1). In order to understand
ill health, then, anthropologists must also know something about issues of well
being. What does the state of good health consist in from society to society? Is
good health merely the absence of illness, or is there something else that defines it?

Figure 1. Nina Etkin, a medical anthropologist, prepares plants in the field.

Paul J. Ross

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In order to answer these questions, anthropologists must work from within a

culture, studying the overall cultural in order to put the particular medical system
into perspective. Though medical anthropologists have a wide variety of
backgrounds within anthropology, medical anthropology is a unified subfield of
anthropology that investigates medical systems cross-culturally, focusing on topics
of health and illness as they have affected human populations, and as health and
illness are perceived by different societies.
Medical anthropology is clearly an integral part of the discipline of
anthropology, but how is medical anthropology integrated with the key
anthropological areas of research? Anthropology is often depicted as a four-part
discipline, in which archaeology, physical anthropology, cultural anthropology and
linguistics are the primary sub-fields. Applied anthropology can be seen either as a
fifth subfield or as a specialized area within each of anthropologys four fields.
Since medical anthropology is a broad field that crosses subfield specializations
within anthropology and also links anthropology with other disciplines, it is similar
in scope to the field of applied anthropology, which is also a broad field that is not
contained by one anthropological subfield. Medical anthropology similarly crosses
subfields, as in prehistoric studies of diet and disease, which links nutritional
anthropology with archaeology. As much of the work of medical anthropology has
practical applications as well (see Chapter One of the Ferraro text for a description
of medical anthropology as an area of specialization in anthropology) it can be
considered part of applied anthropology. Like applied anthropologists, many
medical anthropologists are concerned with applying their research to
contemporary problems, for instance, studying malnutrition in order to alleviate it.
Yet not all medical anthropologists work within an applied framework.
A look at the work of a broad section of medical anthropologists shows the
wide ranging interests and approaches within the field of medical anthropology.
Some medical anthropologists, for example, have degrees in both anthropology
and medicine and focus on traditional and biomedical practitioners of health care,
while others have double degrees in anthropology and public health and focus on
the origins and spread of disease. Other medical anthropologists are trained in very
specific areas within anthropology such as forensic anthropology and
bioarchaeology; and still others work within cultural anthropology focusing on
cultural beliefs about illness and health. Research topics in medical anthropology
range from paleopathology (the examination of ancient diseases through the study
of skeletal material) to the health issues of street kids, to cross-cultural psychiatry.
The broad range of topics studied by medical anthropologists illustrates that
medical anthropology has important links to both medicine, social science, and the
natural sciences, because in looking at health and disease, this field of study
necessarily draws from many areas of investigation.
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Practitioners of medical anthropology are committed to the study of practical

health care issues that help to alleviate medical problems confronted by various
groups of people. The Society for Medical Anthropology (SMA) is an interest
group that has been part of the American Anthropological Association since 1968.
Its diverse membership crosses subfields and disciplines and shows that despite a
wide range of interests, medical anthropologists have created a unified
subdiscipline that is one of the most rapidly growing areas within the field of
anthropology. A closer look at the component groups of this society indicates
medical anthropologys applied aspect: SMA members investigate and disseminate
information on AIDS, bioethics, disability, reproductive issues, emerging diseases,
pharmaceuticals, infant health, and alcohol, tobacco, and drug use. From these
research areas it is clear that in terms of practical applications, anthropologists can
make important contributions to the field of health care because of their ability to
articulate the cultural context in which illness occurs and health care is provided.
AIDS research, for example, has a long history of anthropological attention. The
research contributed by anthropologists has helped demonstrate that it is not
enough to prescribe the use of condoms to discourage the spread of AIDSif
people in a given region either do not have access to condoms or have cultural
beliefs that keep them from using them, then this approach wont be successful and
must be modified to fit the cultural practices of the group. This one example
illustrates that global health issues must be addressed with an understanding of
cultural context, something in which anthropologists excel (see Ferraro text,
Chapter Five, for an applied perspective on anthropological research and AIDS).

MEDICAL SYSTEMS

Within medical anthropology, a distinction is often made between

biomedicine, or the western medical system, and ethnomedicine, or the local
system of indigenous beliefs and practices surrounding health and illness. In
countries such as the US, the notion of health is mainly influenced by the
biomedical system, in which all ill-health is attributed to a pathogen (a biological
agent that causes disease or illness to its host), and the state of health is perceived
as being an absence of disease. Despite the prevalence of the biomedical model in
the US, most people also use ethnomedicine in that they search out alternative
medicines which may not be condoned by the biomedical system, and they also
have beliefs about illness that are not traced to pathogens (e.g., it is dangerous to
go out in cold weather with wet hair). Conversely, in Bolivia where there is an
active system of traditional medicine used by people in rural and urban areas alike,
many people will consult a doctor from the biomedical establishment or a
traditional healer depending on the illness. In this way, most systems of health

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beliefs and care could be called medical pluralism in that they combine elements
from different sources into a system that is meaningful to the individual.

Figure 2. At marketplace stands like this one in Bolivia, a mix of traditional ingredients
and newer imports shows medical pluralism at work. Lynn Sikkink

HOW MEDICAL ANTHROPOLOGISTS WORK:

INTERDISCIPLINARY AND APPLIED ISSUES

Since medical anthropology is such a broad field that draws from a variety
of disciplines and areas of expertise, it follows that the approaches taken to
research and the data collected come from a wide variety of specialists and fields.
Most research problems necessitate using data from different fields and integrating
them, giving medical anthropology the interdisciplinary nature that characterizes it
today.
In order to understand the cultural context of any particular health issue, it is
necessary to have the ethnographic data collected by cultural anthropologists in
the field. This provides the researcher with a broad understanding of a medical
system, and also provides the fine-grained detail necessary for understanding
health behavior. In most places, the so-called medical system is not separate
from religious ideas and practices, and is also embedded in the material conditions
of life, that is, in a societys economic system and way of making a living.
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Ethnographic data, then, provides information on religion, kinship, family

structure, marriage practices, and subsistence techniques, thereby providing a full
account of the people who experience health issues, the conditions of their lives,
what they do when they get sick, and what kinds of perceptions they have about
good health. Ethnographic research collects these data through intense and often
long-term field study. If a researcher wants to understand the Inuit and their
associated health conditions, then this person will need to interview Inuit people,
visit their houses, and watch them as they go about their daily lives. This primary
method of research, called participant observation can be complemented with
collecting quantitative survey data relevant to the issue at hand.
Collecting epidemiological data is also important to medical
anthropologists. Epidemiology is the study of the distribution and determinants of
the various forms of disease in human populations (Helman 1994: 319). These
data come from the fields of the natural and clinical sciences, and provide health
statistics that help researchers to look at diseases and the groups of people at risk
for those diseases. For example, in places where malaria is present, a medical
anthropologist must determine which regions are at risk, and within them, which
people. Although malaria is found in certain ecological settings inhabited by the
mosquitoes that are the vector for the disease, not all people living in these areas
are equally at risk. As Peter Brown discovered from studying malaria in Sardinia,
not only are elderly people and infants more susceptible to dying from malaria,1
but people in lower socioeconomic classes are more likely to contract malaria
because of their work in malaria-ridden areas (1998). Women, and in general all
people in higher economic classes, were more protected because of adaptive
cultural practices, such as migrating to higher elevations in malaria season.
Therefore, Browns research looks at the epidemiology of malaria, i.e., its
distribution and determinants in Sardinia; but in looking at the cultural patterns that
affect this, he also provides ethnographic and environmental data, making this a
good example of the interdisciplinary nature of medical anthropology studies.
Some of the diseases that medical anthropologists study are endemic2, like
malaria, which is an ancient disease that is present in certain communities through
time, but in moderate numbers. Other diseases are considered epidemic in that
they affect a large number of people in a short period of time. The Bubonic Plague,
or Black Death, is a classic example of an epidemic in the way it swept through
Europe and the Middle East in the 1400s, killing more than a quarter of the
1

The same pattern is true for West Nile Virus, another mosquito borne disease, which is
becoming more prevalent in the US.
2
An endemic disease is one that is common to a particular place and found in moderate
numbers, in contrast to an epidemic disease.
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population. Every year flu epidemics spread across the world, affecting millions of
people during flu season.
Alongside epidemiological and ethnographic data, it is also important to
understand the ecological or environmental picture; by gathering data on these
features, the medical anthropologist can help to explain why disease occurs in
particular places in particular times. In the case of malaria in Sardinia, for example,
the incidence3 of malaria was directly related to different altitudinal zones and
settlement sizes, and the ways in which settlements were inhabited by human
populations. Malaria was most commonly found in low-lying rural areas (Brown
1998: 84).
Finally, clinical data has a role to play in medical anthropology by providing
a picture of the diagnosis and treatment of disease in the people it inflicts. Clinical
data help identify who is sick and how to treat disease from a clinical perspective,
but may overlook valuable ethnographic data by focusing too narrowly on the
disease as pathology. For instance, in the malaria example, it is a doctor or health
professional that can identify whether a person is sick with malaria and what kinds
of medicine would be useful in treating the disease. Without looking at the detailed
ethnographic and environmental data however, clinical data would not be sufficient
to understand the broader picture of how malaria in a region can be understood and
combated.
Clinical data will also provide an important distinction between chronic and
acute diseases. An acute disease develops quickly and is over relatively quickly,
like the flu. A chronic disease is one that lasts over a longer period of time, like
malaria or tuberculosis. However, some diseases can have acute and chronic
expressions, as we see in the example of Chagas disease below.
Having examined briefly the various kinds of data that are used in an
interdisciplinary manner in medical anthropology, lets take a look at a specific
case study to see how all these data sets interconnect in a useful way toward
understanding, and eventually eradicating, a serious health threat. Chagas disease
is called a crawling epidemic by Joseph Bastien, in that it is spreading, but
perhaps not quickly enough to gain the attention it deserves (2003:167).4 Chagas
disease is transmitted by the kissing bug called vinchuca in Spanish, which is a
beetle-like bug (Triatoma infestans) carrying the parasite Trypanosoma cruzi. The
bug bites and sucks the blood of a human sleeper at night, leaving a small mark,
3

Incidence is the rate at which new cases of disease occur in a population over a given period of
time.
4
Recently an Inca mummy with Chagas disease has been identified, meaning that Andean
people have suffered from this disease since as least the 15th century. On another historical note,
some researchers claim that Darwin suffered from Chagas disease, which he would have
contracted on his famous voyage to South America.
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and infecting its victim. From an epidemiological perspective, the disease is

endemic to Bolivia, infecting around 60 percent of the population, and is
developing into a chronic problem in about one million Bolivians (Ibid.). It is also
endemic to other parts of Latin America, posing a serious health problem in
particular regions. Chagas disease affects 1618 million people, with one quarter
of the Latin American population at risk of becoming infected, and the disease kills
about 50,000 people each year. Chagas disease is distributed throughout
Americas, ranging from the southern United States to southern Argentina, though it
is most commonly found in poor, rural areas of Central and South America, such
as Bolivia.
Using clinical data, we see that the disease has a complex life cycle, which
includes an animal reservoir population, making it similar to African sleeping
sickness, also caused by a trypanosome parasite. The symptoms of Chagas
disease are so varied (from infection of various internal organs, to boils, to blocked
intestines) that it has been a difficult disease for clinicians to diagnose, and it is
even more difficult to treat. Its acute attacks can kill people quickly, especially
small children, but its chronic phase is incurable and usually fatal within 13 years.5
One symptom alone, an enlarged colon (megacolon) and inability to defecate can
kill the sufferer. In other cases, the disease exhibits different symptoms.
From environmental data we know that Chagas disease becomes more
prevalent in areas that have been deforested, which has the effect of concentrating
bugs around human settlements, where they habituate themselves to humans rather
than other animal prey. The vinchuca bugs move into houses, especially those that
have thatched roofs where they can live, making it very likely that they will infect
the people who live there. Programs aimed at eradicating the disease have therefore
aimed at either killing the beetle in particular environmental zones, or providing tin
roofing material to people who live in thatched roofed dwellings.
Interestingly, from an ethnographic perspective, the diverse symptoms and
associated deaths that clinicians identify as Chagas disease are not associated with
one overarching ailment from the Andean ethnomedical perspective. People who
may in fact suffer from Chagas disease are attributed with a variety of conditions,
such as weakness, fever, colic, and anemia. These conditions are considered
distinct ethnomedical problems. Nonetheless, images of blood-sucking and fatsucking are common descriptions of the cause of various ailments in the Andes.
For instance, in my field area in southern Bolivia, the likichiri is a vampire-like
figure that stealthily sucks fat from victims unbeknownst to them, causing serious
health problems which could end in death. Since health is a state of balance in
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After it moves into its chronic phase, the infected person may not have many overt symptoms
for several years.
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Andean perception, then the loss of body fluids, as would happen when bitten by a
blood-sucking bug in the case of Chagas, would be an obvious cause of illness in
this belief system (Bastien 1998:173).
Prevention measures must take all of these data sets into account in order to
be effective. Working with local people and their perceptions of the illness will
facilitate clinical treatment. Previous efforts that have focused on eradicating the
vectorthe bug that carries the parasitehave been quite effective in Chile,
Uruguay, and Brazil, but less so in Bolivia. In the successful South American
campaigns against Chagas disease, the use of insecticides has been an important
factor in combating the bugs that infect human populations. Perhaps through
similar efforts that focus on eradicating the vector, improving the roofs in rural
Bolivian houses, and using vaccinations that have thus far not been considered
economically feasible, the rates of infection can be brought down.

ILLNESS AND HEALING

One of the central features of medical anthropology is its focus on concepts

of illness and cultural constructions (or perceptions) of illness, including how
illness is experienced and under what conditions and from who help is sought.
People from different cultures tend to label disease differently, and do not
necessarily see diseases from the same perspective as biomedical practitioners do.
In order to understand the multiple perspectives involved, the difference between
disease and illness is a useful distinction. Describing an ailment in terms of disease
signals that the perspective originates from those who practice modern scientific
medicine (biomedicine)it is the doctors perspective (Helman 1994: 101). That
is, disease is caused from some external impersonal force, like bacteria, which gets
into the body and sickens the person. Helman describes the biomedical
establishment as a healing subculture with its own worldview, and in this
worldview, disease results from scientifically identifiable pathogens (Ibid.).
In contrast to this, illness is a term that is used to describe the condition that
is experienced by individuals, who may or may not follow this biomedical model
in explaining the causes of disease. Illness is, therefore, a term that signals the
patients perspective, and so it is not only the experience of a particular disease
by a particular individual, but it is also the meaning that is given to it by the
patient, which is partly influenced by the surrounding community. In many
societies illness can be the result of a personal force from sorcery, for instance. The
various images and phrases that people use when they are ill, such as fighting to
get well, are likewise culturally informed. Because the terms disease and illness
are distinct in their usage, a person may have a disease without being ill, or
experience illness without a disease. For instance, a person may have the medical
condition of Chagas disease (described above) for many years without feeling ill,
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and without being labeled by his/her society as a sick person. Some people with
AIDS do not get very sick while others do. On the other hand, a person can feel
very ill without getting a diagnosis of disease from the medical/clinical
establishment. Many people report various kinds of debilitating illnesses, or
chronic pain, without corresponding clinical diagnoses. Skeptics will reply that the
person is imagining pain (i.e. the condition is psychosomatic) and others blame
the medical establishments inability to find the cause. The important thing to
focus on in this discussion is that regardless of ones value judgment, the sick
person legitimately experiences and suffers from illnessit is all too real from the
sufferers perspective.
Considering this distinction between disease and illness, which indicates that
there are multiple perspectives on ill health, it follows that there are different kinds
of illnesses in different societies. Unique disorders experienced in particular
cultures are called culture bound syndromes. Culture bound syndromes are found
in all parts of the world, including the US; characteristics of culture bound
syndromes are the uniqueness of the condition to particular places, and the
recognition by the society of the legitimacy of the illness even though observable
clinical causes may not be present. In other words, culture bound syndromes
provide another example of the presence of illness (an individuals experience of
it) without a disease (biomedical pathogen). Despite the fact that these illnesses
might have no pathogenic causes from the perspective of biomedical doctors, it
would be inaccurate to think of them as imaginary. Many people experience
perfectly real symptoms and become ill or regain health within the framework of
particular culture bound illnesses.
In some extreme cases, people can actually die from culture bound illnesses.
One of these cases is called magical death by the researchers who have observed
it. It is also known as voodoo death (Cannon 1942), having variants in several
parts of the world, and is not unique to one cultural group. Among Aborigines in
Australia, magical death comes about from being hexed by a sorcerer. The sorcery
victim sickens and dies, believing that he/she is destined to this fate. In some cases,
another sorcerer or a healer intervenes to help the individual recover, but in other
cases the victim is entirely resigned to the negative outcome. The condition has
also been called socio-cultural death in that it originates from the social relations
of a group of people and their ability to influence each other. This final term also
indicates that there is a difference between biological death, when the body passes
away and social death which is the point at which the society views the person as
dying, even if their bodily functions have yet to cease.
Culture bound syndromes are very important to medical anthropologists
because they illustrate the cross-cultural variation in illness and its perception.
Culture bound syndromes take many forms, and have been documented in all parts
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of the world. One good example is the eating disorder that we know as anorexia,
which is a condition only found in the US and other westernized countries, and
found mainly among middle and upper-class girls. Apparently caused by the fear
of becoming fat, the condition also appears to be related to anorectics expression
of unique identities, and the mechanism by which they seek to control their lives
through the control of the body and food (Banks 1994). The disorder sometimes
reaches near starvation proportions, and can even result in death when the body
processes begin to shut down from the imposed physical stress placed on the
system.
One culture bound syndrome, found throughout Latin America, is called
susto, translated into English as fright. It affects certain segments of the
population (poorer, more marginalized) more frequently and signals that the victim
is spiritually vulnerable (Baer 2003). Susto can affect children or adults, and the
symptoms vary by age or individual, but generally the condition causes people to
feel weak and listless. People with susto become pale, and they experience appetite
loss and sleep problems. They are also able to identify a particular experience
when they were first frightenedsuch as an accident, a fall, exposure to harmful
wind or air, or an encounter with some kind of malignant spirit (usually at night).
As a result of this experience the soul becomes separated from the body and this
saps the energy of susto-sufferers and sickens them. In these instances, a ritual
healer must call back the persons soul, and attempt to reunite it with the patient.
Very often the healer is successful in this endeavor, so that it is uncommon, though
possible, to die from susto.
Both patients and healers understand that this kind of illness is untreatable
by a biomedical doctor or through the use of pharmaceuticals. Instead it must be
treated ritually, by calling back the persons soul during a specific ritual, using
bells and voices to bring the spirit back. A good healer is able to change the
outcome of a condition of fright through a variety of meansthe spirit can be
returned to the person or it could become a diminished spirit that needs to be
fixed, augmented, or fortified through ritual practices (Carlos Prado, personal
communication). There appears to be a connection between susto and depression
(or in some cases post-traumatic stress disorder) as understood in the biomedical
system. It may be that the attention focused on the susto patient and the confidence
gained from the ritual treatments allow the patient to rise above the symptoms of
this depression-like state. Interestingly, the healing procedures provided by
traditional medicine specialists are quite effective, and patients report relief from
the sessions.
Culture bound illnesses also illustrate the powerful mind-body connection of
health and illness. Most people have heard of the placebo effect, a term which
comes from clinical studies in which certain segments of the study population only
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receive sugar pills, but often times have positive results without getting the
medication being tested by the researchers. A good definition of the placebo effect
is the positive results in healing that result from positive expectations on the part of
the patient. Therefore, people who expect to get better often do. The flip side of the
placebo effect is the lesser-known nocebo effect (or nocebo phenomenon), in
which people will experience negative results because they have negative
expectations (Hahn 1998). In one study, 80% of hospital patients who were given a
sugar water solution but told that it was an emetic (causes vomiting) subsequently
vomited. This illustrates the powerful effects of expectation on health. Magical
death is the most extreme case of the nocebo effect, then, in that people have the
negative expectation of death, which ultimately causes it in many of these cases.
Though some researchers have argued that in cases of magical death victims have
succumbed to dehydration or starvation rather than some mysterious ailment, we
must still question the powerful nature of a cultural force that induces people to
give up food and water, believing that resistance to their fate is pointless.

Medical Practitioners
Just as illnesses vary cross-culturally, so do medical practitioners. In many
parts of the world, there is a kind of division of labor in healing, which allows for a
wide variety of options and treatments for the person who suffers health problems.
Following a hierarchy of resort6 (McElroy and Townsend 1996, Romanucci-Ross
1989), people who feel ill often first try to treat themselves, and the mother of the
household is often in charge of taking care of the childrens ailments, i.e., she is the
first-order healer in this system. In these instances, sick people are treated with the
common medicines used for a variety of ailments, such as local herbal remedies.
An example of this is the way people all over the world will self-treat colds, using
standard remedies that are recognized within the society as being useful, such as
eating chicken soup. When the illness is more serious, an ailing individual will
consult the next order healer (in the hierarchy of resort), which in many places is
an herbalist, who is a person with a broad knowledge of plants and their medicinal
uses. Herbalists, often known simply as healers (or curanderos in Spanishspeaking regions) know how to prepare herbal teas, poultices, steam baths, and
other herbal preparations. Besides herbalists, highly specialized individuals such as
shamans and biomedical doctors are consulted for something more serious, or after
other options have been tried and have failed. Shaman is a generic term that refers
to the person in societies around the world who is a ritual specialist, but who can
6

A hierarchy of resort refers to the sequence of options people avail themselves of in treating an
illness.

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also diagnose severe health problems. Often but not always a male, the shaman can
travel to the spiritual world to find out what is wrong with the ill person. Ritual
treatments, such as ceremonies that involve not only the patient but the patients
family, are used to heal the diagnosed ailments. The shaman is often a person who
has experienced serious illness and returned from the brink of death. Physicians
may coexist alongside shamans in many places, and people who can afford to do so
may avail themselves of the physicians services as well as the services of the
shaman. In poor countries, however, the physician would be at the end of the
hierarchy of resort because of cost and cultural beliefs. Many people will never
consult a physician in their lives. Midwives, for example, are the specialists who
deliver babies in most places, and midwifery represents one of the oldest
professions. Where access to clinics/hospitals is limited, midwives deliver almost
all the babies, except where mothers are expected to deliver on their own. In
traditional Ju/hoansi society a woman sometimes gave birth alone to show her
courage and strength (Shostak 1981). Finally, bonesetters are a specialized group
of healers found in some societies whose numbers appear to be diminishing. Where
they are active, they not only set broken bones but perform some bone and muscle
adjustments or manipulations, similar to physical therapists or chiropractors (Oths
2003).

Figure 3. A Lacandon Maya Shamanthe Lacandon live in the southern state of

Chiapas, in Mexico. William Coupon/Corbis

In studying this array of traditional healers, who serve various roles and
offer important services, medical anthropologists can formulate ways to work
alongside traditional healers instead of in opposition to them. Programs that

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emphasize the integration of traditional healing with biomedicine have been

successful in bringing broader health care services to communities of people who
are in dire need. For instance, oral rehydration programs focus on providing oral
rehydration therapy (ORT), which consists of administering a simple solution of
clean water, sugar, and salt to children suffering from severe diarrhea. When ORT
solutions are given to weakened children with few other options, many lives are
saved. These ORT programs are good examples of how anthropologists can work
with health care professionals to provide cures that are disseminated through both
biomedical and ethnomedical health channels, providing cures to a very common
cause of death in young children (Kendall et al. 1998).

MEDICAL ANTHROPOLOGY AND FOOD AND NUTRITION

Because food and nutrition are perceived as being directly related to health
and illness by people in all places, it is an important area of study for medical
anthropology. The data collected by medical anthropologists on food and nutrition
from different groups across the world has direct application to the solution of
health problems such as hunger, and in this way medical anthropologists work
within the field of applied anthropology. The topic of nutrition is first and foremost
one of how people meet their basic dietary requirements through the food they eat.
In the United States, calculations of the Recommended Dietary Allowance (RDA),
are used to measure the quantity and quality of food we consume. The study of the
anthropology of food, on the other hand, is concerned with the various cultural
meanings ascribed to food, such as what items are considered proper foods, what
items are to be avoided, and what is considered a necessary food to be eaten on a
daily basis. It is important to note that food has symbolic and social components
that go beyond its strictly nutritional value, such as a consideration of which foods
are served at celebrations, the meaning of people sharing foods together when a
social contract is sought, and what sorts of foods a nursing mother should or should
not eat.
Knowing the symbolic and social components of food is important in
understanding the total food systemfor instance, certain foods wont be adopted
in a nutrition program by certain cultures even if they are highly nutritionalthey
may simply be culturally unsuitable. In the highlands of Bolivia, for example, a
meal is not a real meal without potatoes, which is similar to the central place of
rice in meals in many diets worldwide, especially in Asia. Through green
revolution programs aimed at improving yields, many new varieties of potatoes
have been introduced in the Andes; when adopted, however, these varieties may be
used as a cash crop but not as food for the family as their taste is considered
inferior. Likewise, certain traditional varieties are used for certain purposes, such
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as in the making of chuo (freeze-dried potatoes) and for gifts to extended family
members. In highland Bolivia potatoes are centrally important in symbolic terms as
well as their nutritional value, because they have a part to play in ceremonies and
myth. Staple foods such as rice, potatoes, corn, wheat, barley, sorghum, and
various legumes form the nutritional and symbolic core of diets in various locales.
Conversely certain core foods are considered unsuitable for consumption by
people in other places; in Europe, for example, potatoes were considered to be the
devils food when first introduced. People in 17th century Europe thought that
potatoes were either poisonous, dangerous aphrodisiacs, or at best likely to produce
flatulence (Salaman 1949). Later the potato became such an important food in the
peasant diet of Ireland that when a fungus infected the monocrop, the potato
famine ensued and millions died or emigrated as a result.7

Figure 4. Potatoes are central nutritionally and culturally to Andean diets. They were
domesticated in the Andes before becoming a staple in Europe. Lynn Sikkink

Although the example of potatoes being viewed as unsuitable food may

seem unreasonable to us, most westerners would not eat grubs even though these
are considered a delicious treat in many places, such as in many parts of the
Amazon rain forest. Nowhere do people eat merely to fulfill their dietary
requirementsthey have specific ideas about what constitutes good and bad
food. These food beliefs and practices sometimes emerge from widespread cultural
ideas (e.g., grubs are icky), but also take specific forms in religious prescriptions
such as in the avoidance of pork and beef to varying degrees in Hinduism,
Judaism, and Islam. Many cultures and religions have very specific food taboos, or
restrict food within a social group by age or gender (Caplan 1997, Shieffelin 1976).

Many of those of Irish ancestry in the United States emigrated as a result of the famine, which
spurred a mass migration to the US.
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Demonstrating the strong link to health perceptions, food and medicine are
not always different categoriesmany foods have medicinal values for the people
who eat them. Not only are some foods considered either good or bad by a group
of people for cultural or religious reasons, but food is often thought of in medical
ways and is considered medicine in many places. Consider the widespread notion
that chicken soup is good for people with colds, or that garlic and orange juice
have healing qualities. In Latin America, the hot/cold system, in which foods,
illnesses, environmental conditions, and body types are classified as either hot or
cold, is based on the idea that health is a state of balance, or equilibrium (Foster
1967, Lloyd 1964). In this system of logic, illness results from the body being out
of balance. When a person suffers from a cold illness, for instance, warm herbs
or other remedies must be administered as a way to balance the cold condition.
Similarly, if too much hot food is ingested, then cooling drinks or teas should
end the meal, as a way to bring the body back into a state of equilibrium. Whether
through a classificatory system such as the hot/cold system, or due simply to
shared qualities, anthropologists have found that the categories of food and
medicine overlap in a number of societies. The Hausa, for instance, are an ethnic
group centered in Nigeria who collect and use 235 wild medicinal plants, 63 of
which are also used as food (Etkin 2006). Another example comes from the Andes,
where the use of coca has been mainly as a medicine and stimulant, though it is
also considered a famine food.

Malnutrition
Though food has many important cultural meanings, it is also true that
people can simply have too little or too much of it in their diets, or the diet can
contain too much or too little of certain kinds of nutrients. Malnutrition is the
term that refers to a poorly adjusted diet, which includes cases of undernutrition
and overnutrition. Patterns of malnutrition are related to economics and
undernutrition often accompanies poverty. Indeed most people think of
undernutrition and poverty when the topic of malnutrition arises, but even when we
examine undernutrition itself, there are several possible varieties. The two most
common kinds of undernutrition are protein-calorie malnutrition (PCM) and
micronutrient malnutrition. With protein-calorie malnutrition, the intake of protein
and calories are both insufficient, and people go hungry. PCM is also a common
form of malnutrition in children, and severe forms can lead to starvation. It is
estimated that around 25% of children worldwide are faced with some form of
undernutrition (Dettwyler 1994, McElroy and Townsend 2004), which can lead to
stuntinglow height for ageor worse, wastinglow weight for age, also known
as marasmus, or starvation (Martorell 1989). Wasting in particular can lead to
developmental problems if not corrected, but one of malnutritions potentially
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lethal complications is the number of children who die from infections because
their under-nourished systems are too weak too fight them off. A common form of
undernutrition in some parts of the world goes by the name kwashiorkor, which is
an ailment that results from sufficient calorie intake, but too little protein. The
disease is also known as the weaning disease because this is the stage when it
often develops in children, as they are weaned from breast milk onto a highcarbohydrate diet (such as cassava or rice) with little to no protein to accompany it.
Sometimes after the arrival of a new infant, kwashiorkor results in the older sibling
because the mother weans the older child earlier than she otherwise would.
Kwashiorkor victims have a pudgy look about them because of edema (swelling)
in their limbs, bellies, and faces, which gives them a moon-faced appearance,
though they have muscle wasting and may actually be starving to death.

Figure 5. A victim of kwashiorkor, a severe form of protein malnutrition, also called the
weaning disease. Stephen Morrison/epa/Corbis

In her study of nutrition and infant feeding practices in Mali, Katherine

Dettwyler found that a high percentage of children suffered from undernutrition,
especially in urbanized areas where mothers were away from home working at
wage labor jobs. Though kwashiorkor was relatively rare in Mali, there was a
widespread problem with undernutrition, some of it in the form of PCM as
marasmus, and some of it due to lack of specific micronutrients. For instance,

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Vitamin A deficiency, which can cause blindness, was a problem in many places.
One of the development programs that introduced carrots (for their Vitamin A
content) and other vegetables into village gardens was not successful because
people did not adopt carrots as part of their daily sauces, a staple of their diets.
Iodine deficiency was another problem in Mali, leading to goiter; this condition is
found in many parts of the world where iodine does not occur naturally in the soil
and/ or there is no seafood in the diet. Goiter would seem to be easily
preventablethe problem lies in how to introduce iodine in such a way that most
people will be able to access it. For instance, not everyone will buy and consume
store-bought, iodine-enhanced salt.

Figure 6. Malnutrition disproportionately affects children. Sanitation and clean water are
important contributors to healthhere children in Mali draw water from a well.
Atlantide Phototravel/Corbis

After looking at the overall pattern of nutrition in Mali, Dettwyler claims that
only some of the malnutrition she documented could be attributed to poverty, and
that it was the attitudes and beliefs of caregivers and households that contributed
significantly to the nutritional well being of children. Some caregivers believed, for
instance, that children did not need good food, since they didnt work like the adults
in the household. Other households, though poor, managed to feed children well and
had few malnourishment problems. Therefore, in looking at the issue of malnutrition
on a global scale, Dettwyler states, the vast majority of malnutrition in Third World
populations does not have one primary cause [such as poverty] (Dettwyler 1992).
Though she believes that poverty relief programs are an important factor in
resolving some of the malnutrition in Mali, she also advocates introducing programs
that provide self-help like credit associations that allow women, in particular, the
ability to control their own lives and help their children in so doing. Dettwylers
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focus on nutrition programs that are culturally appropriate and adjusted to specific
local livelihoods and beliefs illustrates the intersection between medical and applied
anthropology in an approach to nutrition (see Chapter 11 in the Ferraro text for a
case study on Improving Child Nutrition in Malawi).
Overnutrition is another form of malnutrition, which results in obesity and
associated health problems. This condition is called overnutrition because it results
from a surplus of calories, usually in the form of fat and sugars, but it could also be
considered undernutrition in that not enough of certain foods (vegetables, fruit, and
whole grains) are being consumed. Although around 10% of the households in the
US experience some food insecurity which can lead to undernutrition of its
members, over half of Americans are overweight, as measured by a Body Mass
Index8 of 25% or more, and these obesity rates continue to rise. Childhood obesity
is one of the most problematic aspects of this figure, as it is so directly related to
the early onset of diseases such as diabetes, high blood pressure, gall bladder
diseases, and associated heart problems, and sets kids up for a lifetime of ill health
(see the Applied Perspective in Chapter 12 of the Ferraro text for a discussion of
diabetes among Mexican-Americans, and the Applied Perspective in Chapter 16
for a discussion of obesity as a health issue). Like adults, childrens overnutrition
arises from a combination of eating high calorie, high fat processed and fast foods,
which are also cheaper than high quality foods such as fruits and vegetables. This
overnutrition pattern has been dubbed an epidemic in the US and was dramatized
in the movie Supersize Me, which shows the effects of a fast food diet on the
filmmakers health in just a short span of time. The film also documents how the
problems with obesity begin in childhood when kids get poor food in school lunch
programs and begin a pattern of inactivity, for instance playing video games
instead being involved in more active play. Many people wonder why a country
with such a high standard of living such as the US achieves should also be plagued
with the chronic health problems that are related to poor nutrition, and there is an
increasing recognition that we need widespread nutrition programs to curb the
trend of obesity-related health problems.
Subsistence and Nutrition Patterns
In order to understand variations in the diets of the worlds populations,
medical anthropologists draw on data from across a variety of cultures, which
demonstrate patterns in food-getting techniques. Comparing and contrasting types
of food procurement patterns from hunting and gathering to farming helps medical
anthropologists to assess the advantages and potential problems in dietary systems.
From this information, medical anthropologists can serve as valuable consultants in

The Body Mass Index, or BMI, is calculated from a persons height to weight ratio.
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offering nutritional program information. For instance, to put the dietary and
nutritional patterns of the US and Mali case studies into broader cross-cultural
perspective, it is useful to look at how food is procured by other societies. The US
represents an industrial pattern in that most of us do not produce our own food, but
instead acquire it through markets, which allows us to choose from a variety of
options. The food that is produced through agriculture in the US is increasingly
done on an agro-industrial level. In non-industrial food-getting systems, people
rely on their environments and their own skills to provision themselves and their
families. Following, the subsistence (food-getting) patterns of four different
groups of peopleforagers, pastoralists, horticulturalists, and intensive
agriculturalistsare discussed in terms of overall nutritional patterns. Examples of
the four subsistence systems come from the contemporary world, though before the
industrial pattern began to predominate, there were many more people making a
living in these particular systems.
Foragers
Foragers are also known as hunters and gatherers as they rely on wild food
which they collect from their surrounding environment. Where feasible they also
fish, so we could call them fisher-gatherer-hunters; foragers is a better shorthand
label. Today the few remaining foragers, such as the Ju/hoansi of the Kalahari
desert, the Inuit of the arctic, and various Amazonian forager groups are found in
remote and marginal environments, where other kinds of food-getting arent viable.
Foragers were much more numerous before the introduction of farming in human
history and they occupied all types of environments, including those rich in natural
resources. Imagine the foragers who lived in the Bay Area of California where San
Francisco and other Bay Area communities now stand. These Native American
people, known as Ohlones, had fish, shellfish, and all kinds of water fowl in
abundance, as well as many different varieties of plants, a temperate environment
with comfortable year-round temperatures, and many resources for building their
houses and fishing vessels. Because of the rich and inviting environment, this region
was the most densely populated area of what is now the United States (Margolin
1978). In contrast to this picture of a lush existence, the contemporary foragers of
the Kalahari Desert of southern Africa seem to have a hard life. But despite the dry
environment and difficult living conditions, the Ju/hoansi (once known as
Bushmen) manage a wide resource base. They hunt over 50 varieties of animals
and gather over 100 varieties of plants, including the high-calorie nuts known as
mongongo, which forms a core of their diet and can be stored over short periods of
times (Lee 2003). The examples of the Ohlone and the Ju/hoansi illustrate a key
feature of the foraging dietit is varied in its base, relying on many different
species, and it is diverse and well-balanced in its nutritional composition.
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Figure 7. Ju/hoansi women of the Kalahari Desert eating honey, a wild and highly
desired food. Anthony Bannister; Gallo Images/Corbis

In their daily rounds of food gathering and hunting, foragers also get plenty
of exercise. They are therefore not only well-nourished but also physically fit.
Before contact with Europeans, foragers suffered very few heart problems or
problems with the common crowd diseases (flu, colds, tuberculosis). Their diets
provided them with the necessary calories, proteins, vitamins, and minerals that
mark a well-balanced diet. Micronutrient deficiencies were unlikely due to the
wide variety in their diet. The potential limiting factor in the foraging diet was in
occasional food shortages and seasonal shifts in what they had available to eat. For
instance, the Ju/hoansi experience a lean period of the year, during which there
is less food available, and their body weights dip correspondingly (Lee 2003).
Nonetheless, the diet of hunter-gatherers is generally one of the most varied diets
in terms of diversity and balance of all the systems we examine here.
Contemporary nutritionists have even used this diet as a model for what modern
westerners should include in their diets, describing how we need to get back to our
ancestral past (such as the Paleolithic, or paleo diet). Unfortunately, the pure
forager subsistence pattern is rare in the modern world. Most contemporary Inuit
(Eskimos), for example, rely only in part on hunting and foragers such as the
Ju/hoansi have adopted more and more farming and wage labor into their
livelihoods. Though they still do a little foraging on the side, many foragers have
almost completely left their old subsistence patterns behind such as contemporary
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Ju/hoansi, whose livelihood today depends on wage labor, crop cultivation and
animal herding, along with a small amount of foraging.

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Pastoralists
Unlike foragers, pastoralists are herders of domesticated animals, whether
these animals are cattle, sheep, horses, camels, yaks, llamas, or reindeer. Though
pastoralists may rely on some non-animal products as a portion of their diet,9 they
are considered pastoralists if 50% or more of their diet comes from animal
products. It is not usually meat itself that forms the core of their diet, since this
would involve killing too many of their herd animals and depleting the stock on
which they rely, but rather they more frequently drink the milk of their animals, or
in some cases take the blood from living animalsboth of which are renewable
resources. This provides them with a high protein diet with adequate fat.

Figure 8. Photo of the Wodaabe pastoralists of Africa, with their cattle and camel
livestock. Tiziana and Gianni Baldizzone/Corbis

One East African pastoralist group, the Ariaal, demonstrate some of the
patterns typically found in pastoral nutrition (Fratkin 2004). For the Ariaal, milk is
their main staple, providing 75% of their daily calories and 90% of their protein in
the wet season. In the dry season, as milk supplies dwindle, blood is added to the
9

They either grow a few food crops themselves, or trade their animal products in the marketplace
as a way to supplement their diets.
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milk, providing another important dietary component, and the meat from some
small livestock is consumed. The Ariaal also sell animals periodically in order to
purchase items such as corn meal, tea, and sugar (Fratkin 2004). The limiting
factor of this particular diet is that it may suffer from being low in carbohydrates
and particular vitamins and minerals; it is for this reason that some pastoralists
supplement their diet with grains and/or store bought food. Pastoralists are also at
risk of going hungry when they lose their animals due to epidemics that affect
animals and/or during drought. In recent years, partly due to circumscribed herding
areas, many pastoralists (similar to foragers) have been faced with food shortages,
and some of them have had to rely increasingly on food handouts. This has been
the case for one of the Ariaals neighboring groups, the Turkana, a very isolated
pastoralist group in the past, who today have become the focus of some of the
largest famine relief efforts in Africa (Fratkin 2004).
Horticulturalists
The diet of horticulturalists is based on domestication, too, though they are
mainly crop-growers. Unlike other agriculturalists, horticulturalists have small
garden-like plots, which they may have to move on a periodic basis when the soil
is depleted. Their plots are garden-like in size, where they grow a diversity of
plants tended with hand-held tools and a large dose of intense human labor.
Because of this extensive pattern of moving their plots as needed and clearing new
land to do so, horticulture is also known as swidden agriculture, or slash and
burn farming; the vegetation on the new plots is often burnt before planting, and
the mineral rich ashes aid the growth of the new crops.
Tropical farmers like the Yanomam are a good example of the horticultural
subsistence pattern. Inhabiting a region of the Amazon basin that straddles the
border of Venezuela and Brazil, they grow their food crops of manioc, plantain,
sweet potatoes, avocados, papayas, and peppers, and supplement their diet with the
hunting and gathering of wild plants. Like many horticulturalists, the Yanomam
rely mainly on one main starchy food item, in this case the plantain. The
Yanomam food-getting pattern relies on the staples produced from their garden
plots and on foraging practices, which defines their horticultural lifestyle (Chagnon
1992). Many tropical horticulturalists have similar patterns, in which they rely on a
main starchy crop for the basis of their diet, whether it is manioc, sweet potatoes,
yams, sago, or taro. In contrast to the pastoralist diet just discussed, therefore,
horticulturalists have plentiful sources of carbohydrates in their dietsbut their
meals are high in bulk and low in nutrients. This nutritional problem may be solved
by the animal protein they bring into their diet (either through hunting or by
keeping domesticated animals such as pigs and chickens), or by growing or

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gathering a variety of other plants to add to the diet. Nonetheless, the limiting
factor of the horticultural diet tends to be protein and fat.

Figure 9. Yanomam of the Amazon basin live a horticultural existence.

COLLART HERVE/Corbis SYGMA

Intensive Agriculturalists
Though modern farmers mainly use heavy equipment and petroleum to grow
their crops, farmers who are self-provisioning do not use heavy equipment to farm.
Sometimes known as peasant farmers or intensive agriculturalists, these groups
differ from horticulturalists in that they use the same plots of lands over and over
again by fertilizing, irrigating, terracing, applying intensive human labor and, when
necessary, letting the land rest (fallowing) so as to be able to re-use the plots.
In general, intensive agriculturalists have one major staple at the core of
their diets, which is often a cereal crop like wheat, barley, rice, corn, millet, or
sorghum. These food crops frequently make up the bulk of the diet and become
very important symbolically, as we discussed in the case of potatoes. Insofar as
these staple crops can be stored, they serve as a food reservoir or safety net to help
people get through times of the year well after harvest. But crops are susceptible to
frost, pests, and blights, and there is always the risk that a particular harvest will
fail. This is one of the reasons that ancient farmers were foragers as well as farmers
(as a fallback subsistence pattern, or supplement) and that peasant farmers at times
offer their services in the wage labor market. Farming has always been a risky
business.
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Figure 10. Intensive Agriculture in Boliviafarmers in their fava bean field.
Lynn Sikkink

Aside from the crop risk, the limitation of the intensive agricultural diet is
that the diet is often narrowly focused on one staple item, which supplies
carbohydrates and bulk, and some vitamins and minerals, but not a full
complement of nutrients. There is less diversity than most horticultural diets, and
this can lead to some nutritional problems. In some societies, this was solved by
eating several plant foods together that complement each other, like the
corn/beans/squash triad. In other areas, people suffered from micronutrient
malnutrition because even though they might have had fairly plentiful food with
adequate calories, their diets were missing key nutrients. The following examples
or micronutrient malnutrition are all linked to different problems in intensive
agricultural diets.
Micronutrient Deficiencies

Pellagra is one example of a micronutrient disease, which comes from both

a deficiency of niacin and protein in the diet. This is commonly found in diets that
rely heavily on corn (also called maize) with little other food to supplement the
corn diet. The disease is characterized by diarrhea, a rash, and mental disorders.
Interestingly, this disease was not common in the corn-based diets in Central
America because they softened their corn with alkali (producing the hominy eaten
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in dishes like posole), which had the secondary effect of increasing the availability
of niacin and protein in the corn.
Similarly to corn-based diets, people whose diets depend mainly on rice
supplemented with little else, run the risk of developing a condition known as
beriberi, which is caused by a thiamine deficiency. Beriberi can affect the nerves
and lead to paralysis, or it can cause heart problems. The addition of thiamine to
the diet will curtail beriberi.
Diets that lack vitamin A can lead to xerophthalmia, which is a leading
cause of blindness today. We looked at the problem with Vitamin A deficiencies
when examining the case of malnutrition in Mali; Mali also has a high incidence of
goiter from iodine deficiency, as already noted. Vitamin A can be added to the diet
as a nutritional supplement, but the problem is how to get the supplements to
people who need them. It is more reliable to have a source of Vitamin A in the diet
that people consume on a daily basis, like carrots.
These micronutrient diseases illustrate that the diets of intensive
agriculturalists, although more stable in some ways than the other subsistence
patterns discussed, also have their risks. People in agricultural societies may be
eating sufficient food, but if it is not of the right kind they will develop nutritional
problems nonetheless.
Medical anthropologists play key roles in not only identifying nutrient
deficiencies, but in helping to develop and implement culturally-appropriate
nutrition programs. A case from Thailand provides one of the best success stories
for alleviating problems of malnutrition. Calling upon the help of nutritional
consultants, the government dedicated its efforts to reducing the malnutrition
problems faced by many Thai peoplein 1982 about 50% of the population
suffered from undernutrition or micronutrient malnutrition, especially vitamin A
deficiency and iodine deficiency. The overall program was multi-faceted, and
included education programs, improved health care, supplemental feeding of
young children, improved production of food, and a program to correct detrimental
food beliefs (cited in Bryant et al. 2003: 318-319). One small change introduced as
a result of the Food and Agriculture Organizations work, in cooperation with the
Thai government, is that vitamin A, iron, and iodine were added to the instant
noodle seasoning packet that many people consumed; this one action made
micronutrients available to a large cross-section of the population. Perhaps because
the Thai program covered so many aspects that affect nutrition, and the
government was so determined to make a difference, the positive results were
dramatic. By 1990, the malnutrition level in Thailand had dropped to under 20%;
by 1998 it was under 10% (Bryant et al. 2003: 318-319).

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BIRTH AND REPRODUCTION

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The topic of birth and reproduction is interesting to examine from the

perspective of medical anthropology because though birth is a biological process, it
is everywhere culturally elaborated. Features like fetal development are
unquestionably biological (though even this is influenced by the mothers behavior
and the environment) but other features such as ideas about conception, proper prenatal care, birth positions, who should attend the birth, how the placenta should be
handled after birth, and post-partum care of both the mother and baby are all things
that vary greatly from culture to culture.
Where do babies come from? A child asking this question in some societies
might be told that the baby develops from the union of a mans sperm with a
womens menstrual blood. This belief was quite widespread, and accounts for the
fact that couples in some cultures believed that through intercourse a man would
cut the woman from her moon and produce a child (Shostak 1981). Many
societies developed birth control practices in order to reduce the chance of
pregnancy. By 1500 B.C. in ancient Egypt, there is evidence that women used
cervical plugs of various sorts. The earliest condoms were made of sheep gut.
Herbal medicines provided another route to birth controleither they were used to
reduce the chance of pregnancy, or they were used to induce abortions. These
abortifacients are still common in many places, perceived in some societies as
being ways to restore the menstrual cycle, rather than ways to affect a
developing fetus.

Pre-natal Care
Pre-natal care also varies from culture to culture. Although in the US there is
an increasing emphasis on pre-natal classes and preparation for birth, in reality prenatal instruction is highly variable and depends on socioeconomic level. In
Sweden, for example, where there is socialized medicine, pre-natal care is more
widespread across ethnic and class divisions; in the Yucatan where traditional birth
attendants are common, pre-natal education is not formalized, and the new mother
receives the information she needs from the midwife during labor, though prior to
this she is visited by the midwife who gives her massages (Jordan 1993). Beliefs
about the difference between male and female fetuses reveal cultural beliefs about
gender relations. In Ecuador, gestation periods for boys are believed to be nine
months, while girls gestation period is eight months. Boy and girl babies
umbilical cords are cut to different lengths based on beliefs about the control of
promiscuity (McKee 1995). Even beliefs about food and cravings during
pregnancy are highly variable. In some societies people believe that a pregnant
womans food cravings must be satisfied or the fetus will be endangered, while in
other places certain foods are on the taboo list for pregnant women.
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Birth Practices
The actual birth itself is accomplished in a number of ways. In some
cultures, like the Ju/hoansi of the Kalahari Desert, women were expected to be
stoic and to have their babies on their own when the time was right. Women were
often proud of this accomplishment as a way of demonstrating the value of their
work (Shostak 1981). In many places midwives attended the birth and still do so
todayeven in the US it wasnt until the early 1900s that doctors became the
primary attendants over midwives, partly because of biomedicines increasing
status, and more recently because of medical liability issues.
As one case study of birth in cross-cultural perspective, Jordan documents
the life of Doa Juana, a Yucatecan midwife who learned to deliver babies by
helping at births, and had successfully delivered over three hundred babies with
very few complications (Jordan 1993). A big difference between the delivery of a
baby by a midwife and by a physician is that a midwife attends the laboring
woman during the whole process while the doctor is often there only for the final
phases. This is important because studies have shown that a constant attendant is
important to positive birth outcomes. Birth outcomes are improved even in
situations where the attendant was only an observer (Jordan 1993).
Position of the mother during labor is another variable feature of birthing
practices. Only in places where women routinely give birth in hospitalssuch as
the US, where 99% of all babies are delivered in hospitalsis the standard birth
position the lithotomy position (flat on back). In other birth systems it is more
common for women to squat or kneel, and to give birth at home. After making a
cross-cultural assessment of the birthing practices in four culturesthe US,
Holland, Sweden, and the Yucatan, Jordan concludes that birth has been
increasingly medicalized in systems such as the US, because of the availability
of medical technology and a legal system under which physicians operate that has
hampered womens ability to choose the birth they want.10 Medical anthropologists
question whether this medicalized birth system should be exported to other parts
of the world, where women currently have options that are often more accessible,
affordable, and socially preferred.
Post-partum Beliefs and Practices

After the birth, cultural differences continue to influence the way in which
the mother and child are cared for and perceived. Among the Hmong, for example,
the placenta, sometimes considered the companion of the baby or its protector
10

This subject is also taken up in the film Born in the USA in which the medicalization of birth
is documented as well as alternatives to the standard biomedical birth system.
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(in the Hmong language placenta means jacket), is often buried close at hand. It
is not thrown away (e.g., Fadiman 1997). In many cultures the mother is often
secluded for around 40 days, during which time she gradually adjusts to her new
child and eats fortifying foods before resuming her regular tasks. In Ecuador this
40-day period is called la dieta, and is seen as important in protecting the mother
along with her newborn, from outside contagions (McKee 1995). The baby will be
kept close to its mother in this scenario, and is held and fed frequently. On the
other hand, this pattern can be disrupted by new economic conditions. When
women migrate from rural areas of Brazil to urban shanty towns, where they take
up poorly-paid wage labor jobs, their children suffer from the mothers absence
and reduced care, and infant mortality increases. Scheper-Hughes found that
women offset the emotional difficulty of this high infant mortality rate through
selective neglect in which only the strongest babies survive, and the mothers do
not end up with an overwhelming number of children for whom they cannot care
properly (Scheper-Hughes 1998).

HEALTH CARE AND CHANGE

When anthropologists document changes in the infant mortality rate and

mothers relationships to their newborn babies in situations of migration, they are
studying the effects of culture change on health care. Being part of cultural systems
that are constantly in flux, medical systems are also part of the picture of change.
But as culture change accelerates around the world, and more people are brought
into closer contact with each other, health care systems are undergoing enormous
change, sometimes losing valuable resources such as elders knowledge of herbal
remedies. Disease itself can bring about culture change, such as when the Native
North American population was decimated by introduced diseases such as
smallpox and measles. But culture contact also brings about change. For instance,
before contact with Europeans, the Inuit of Canada were foragers with remarkably
good health; accidents were the most frequent cause of death (McElroy and
Townsend 2004: 319). The Inuit food supply was varied, like other foragers, and
they did not suffer from infectious diseases. After contact with Europeans,
however, not only did they begin to suffer from crowd diseases like flu,
pneumonia, syphilis, and tuberculosis, but their diets changed to include more
processed foods with lots of carbohydrates, which led to an increase in obesity,
diabetes and heart problems. Tobacco and alcohol use also increased the Inuits
health problems (McElroy and Townsend 2004).
One of the pressing issues in the study of worldwide health and illness is the
AIDS pandemic (global epidemic). Caused by a retrovirus called the Human
Immunodeficiency Virus (HIV), the immunology and epidemiology of AIDS have
received a lot of attention and study from researchers, but the social and cultural
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context of AIDS spread and effects have received less attention. (See Ferraro
Applied Perspective from Chapter Five for a discussion of AIDS Research, and
Chapter Three for information on public health in South Africa.) In addition to the
human suffering it exacts, AIDS can also be examined in terms of the disruptions it
causes to social and health care systems (Farmer and Kleinman 1998). To
understand who is at risk for AIDS, and how it spreads, medical anthropologists
look at the ethnographic data about how and when the people interact, and under
what conditions. Since what people do is not simply guided by rational choice, but
also by their cultural values and emotions (Bolton 1998), developing an effective
anti-AIDS program cannot work merely by spreading the right information. What
anthropologists and other social science researchers can show are the cultural
values and particular emotions that are important in shaping the behavior of a
particular people. Medical anthropologists can work to understand AIDS
transmission and prevention, but they can also help to design culturally appropriate
strategies for prevention of the spread of AIDS.

SUMMARY

In looking at global health issues, and the ways in which societies treat these
problems, medial anthropology serves the important function of linking local
beliefs and practices to culturally-acceptable solutions. Drawing on their valuable
expertise, more medical anthropologists are beginning to work within the health
care profession, some of them serving as cultural brokers for patients for whom
the biomedical system is foreign, and others working to provide an understanding
of how ethnomedicine and biomedicine can be beneficially integrated.
Medical anthropology explores beliefs and practices surrounding healing,
how people stay healthy, and to whom they turn when they are sick, by examining
cross-cultural perspectives on health and illness. At the same time, because
medical anthropology is a broad field within anthropology that links various
subfields in anthropology and is also concerned with practical applications, it
provides a good example of the work of applied anthropology. By looking at
culture-bound illnesses, medical anthropology helps to expose the important mindbody connection in illness and healing, and suggests that this understanding is a
useful feature of maintaining good health, about which biomedical health care
providers need to be aware. It is even evident that the belief in negative outcomes
(the nocebo effect) can contribute to health problems, and thus must also be
understood by health care practitioners.
Medical anthropology also offers basic data on traditional medical practices
from various cultures. Where traditional healers offer valuable services in
complementary ways to biomedical doctors, such as in Bolivia and China, more
positive health care options are available. Understanding the valuable roles of
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spiritual healers, midwives, and herbalists allows us to see the ways that
biomedicine could become even more effective. For instance, the issue of
malnutrition revolves around not just food, but the cultural practices surrounding it.
Medical anthropologists who study nutrition can shed light on how to supplement
traditional dietswhich are already nutritional in many wayswith what are in
some cases needed vitamins and minerals. Along a parallel vein, traditional birth
attendants offer important services to mothers in places where biomedical care is
often absent. Therefore these roles should be encouraged instead of discouraged in
rural outreach programs. The topics in medical anthropology discussed here are
certainly not exhaustive, but do provide an idea of the wide-ranging field of
medical anthropology, and the practical applications of its subject. The particular
case studies in this module also provide specific insights into how medical
anthropologists can conduct meaningful research that will allow them to apply
their knowledge to contemporary health issues.

KEY WORDS / DEFINITIONS

AIDS and anthropology the use of anthropological knowledge and techniques

to help with the prevention and treatment of AIDS
Abortifacients traditional medicines used to induce abortions
Acute disease a disease that develops quickly and is overly relatively quickly
Anorexia eating disorder leading to unhealthy weight loss, classified as a
Culture bound syndrome medical condition(s) unique to particular places
Ariaal East African pastoralists, who live in Kenya, and whose reliance on both
cattle and camels has allowed them to succeed during droughts
Beriberi a thiamine deficiency that leads to serious disease; one of the
micronutrient diseases that comes from an all-rice diet
Biomedicine scientific medicine or the western medical system in which disease
is caused by the occurrence of a pathogen
Bonesetters Traditional medical specialists who set broken bones, adjust skeletal
muscular injuries, and even deal with the internal organs in some cases.
Chagas disease endemic disease found in Latin America caused by the
trypanosome parasite and spread by the kissing bug
Chronic disease a disease that persists for a long time; sometimes not curable
Clinical data Data from the biomedical sphere, including doctors diagnoses,
which is useful in understanding an issue in medical anthropology
Culture bound syndromes illnesses that are unique to certain societies or
cultures, and are not found worldwide

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Disease in medical anthropology, this is the biomedical definition of the patients

condition; contrasts to illness
Ecological/ environmental data Data from biology, ecology, and other natural
sciences that helps medical anthropologists understand the material conditions of
an issue
Endemic diseases Diseases that are unique to a particular locality, spread
slowly, and are found at some level at all times in the region
Epidemic diseases Diseases that spread rapidly and extensively among many
individuals
Epidemiological data Data from epidemiology, which helps understand the
cause and spread of diseases
Ethnographic data Data originating from the particular cultural features of a
given group of people, helping medical anthropologists to understand the cultural
context
Ethnomedicine The local and particular medical beliefs of a particular group of
people, systems of medical beliefs that do not perceive illness as the result of a
pathogen
Extensive agriculture (same as horticulture) Farmers who cultivate by relying
on extending plots into new territory, and not on continuous use of the same plots
Fallowing allowing agricultural plots of lands to rest in order to become fertile
again; technique used in intensive agricultural systems
Food, the anthropology of beyond nutrition, this is the cultural and symbolic
elaboration of ideas about food in which only certain foods are suitable, some are
taboo, and some have core symbolic value
Foragers a system of food-getting that relies on hunting wild animals and
gathering wild plants
Goiter a micronutrient deficiency that comes from lack of iodine in the diet;
causes a swelling at the front of the neck
Herbalist Specialist in the collection, prescription, and use of herbs; usually
found in ethnomedical systems that rely on particular plants to cure particular
ailments
Hierarchy of resort when a person is ill, this is the trajectory they follow in
treating their illness; people first consult lower level healers before consulting
specialists, whether these specialists are shamans or physicians
Horticulturalists same as extensive agriculturalists; gardening-style agriculture
in which hand-held tools are used, land is cleared by slash and burn (swidden), and
new plots are opened as the old ones lose their fertility
Hot/cold system the Latin American humoral theory of disease causation and
treatment. In this system, hot and cold foods, body conditions, and medicines must
be balanced to achieve health
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Illness the patients perception and experience of sickness. Contrasts to disease

Incidence the frequency of occurrence of a disease in a population
Intensive agriculturalists Farming system in which plots of land are used over
and over; relying on the techniques of fallowing, irrigation, terracing, fertilizing,
and large farming implements like plows
Inuit Arctic foraging group who relied on mainly animal sources; Eskimos
Ju/hoansi (also! Kung) forager (hunting and gathering) group of the Kalahari
Desert who live in small bands, and have a very diverse and well-balanced diet
Kwashiorkor also known as weaning disease; form of undernutrition that
results from too little protein and other vitamins in the high carbohydrate diet
Likichiri fat-sucker; in the Andes, this vampire-like creature is considered to
be the cause of illnesses; relates to the local perception of Chagas disease
Lithotomy position Flat on the back position, only common in hospital births
Magical death When an individual is cursed or hexed by a sorcerer, the
individual will actually sicken and die because of negative expectations. Extreme
form of the nocebo phenomenon
Malnutrition poor nutrition because of insufficient or poorly balanced diet; two
kinds of malnutrition are undernutrition and overnutrition
Marasmus a wasting away of the body, associated with protein-calorie
malnutrition
Medical pluralism the blending or simultaneous use of two or more medical
systems; and example is the use of Chinese medicine by someone who also goes to
a biomedical physician
Midwives traditional birth attendants. In ethnomedical systems, they receive
their training through informal apprenticeships in which they help with deliveries
Nocebo effect (or nocebo phenomenon) - negative health expectations result in
negative health outcomes; the opposite of the placebo effect
Nutrition the process by which the body is nourished; how an organism
assimilates food
Ohlones indigenous foraging people of the San Francisco and Monterey Bay
Areas
Oral rehydration therapy a way to combat the dehydration that results from
severe diarrhea; life-saving technique that has become the focus of public health
programs in many places
Overnutrition excessive intake of food, this is a type of malnutrition
Micronutrient malnutrition a type of malnutrition in which one key vitamin or
mineral is lacking, such as vitamin A deficiency, or iodine deficiency
Paleopathology The study of disease in antiquity, relying mostly on skeletal
material, but sometimes tissue in the case of mummification

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Pandemic an epidemic that is spread over an especially wide area

Participant observation a hallmark fieldwork technique in anthropology in
which the researcher learns by participating and observing simultaneously
Pastoralists a food-getting strategy that is based on the herding of domesticated
animals
Pathogen an agent that causes a disease, such as a bacterium or fungus
Pellagra caused by niacin deficiency, this micronutrient disease is found in some
all-corn diets, such as the share-cropping diets of southerners
Placebo effect expectation of positive health effects leads to positive health
outcomes; the opposite of the nocebo phenomenon
Protein-calorie malnutrition (PCM) very serious type of malnutrition in which
the person is getting too little protein and calories, which results in marasmus, or
wasting
Shaman a generic term referring to a ritual specialist who is able to contact the
supernatural world to diagnose a treat a patient suffering from health problems
Sociocultural death another name given to magical death, to indicate that the
expectation of the group is that the hexed person will die; contrasts to biological
death
Stunting inadequate nutrition will sometimes lead to under average heights but
average weights; not as severe as wasting
Susto translated as fright, this culture bound syndrome is
Swidden another name for the slash and burn agricultural technique, in which
land is cleared for planting, and sometimes burned, allowing the soil to be naturally
fertilized
Turkana a group of East African pastoralists, neighbors of the Ariaal, who
have relied heavily on food handouts in recent years
Undernutrition one form of malnutrition; either protein-calorie malnutrition
or micronutrient malnutrition
Wasting the most severe form of malnutrition; same as marasmus
Yanomam - a horticultural group of the Amazon basin whose territory spans the
region between Venezuela and Brazil.

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QUESTIONS FOR REVIEW OR DISCUSSION

1. How are medical anthropology and applied anthropology linked to each
other? How is a health issue like AIDS of concern to both medical and
applied anthropologists?

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2. What is the difference between disease and illness, and why is this
distinction important in medical anthropology?

3. What does medical pluralism mean? Can you describe a situation of

medical anthropology either in your health care practices, or from people
with which you are acquainted?
4. What are the various types of malnutrition? Why is the topic of diet and
nutrition important to medical anthropology? How does the topic of the
anthropology of food differ from nutrition?

5. Describe a hierarchy of resort with which you are familiarthat is what

was the sequence of health care professionals involved in treating a
particular illness? Why was that particular order followed?

SUGGESTED FURTHER READING

Bryant, Carol, Kathleen DeWalt, Anita Courtney, and Jeffrey Schwartz. 2003. Second Edition.
The Cultural Feast: An Introduction to Food and Society. Belmont, CA: Thomson Wadsworth.

Dettwyler, Katherine. 1994. Dancing Skeletons: Life and Death in West Africa. Long Grove,
Illinois: Waveland Press.

Etkin, Nina. 2006. Edible Medicines: An Ethnopharmacology of Food. Tucson: University of

Arizona Press.

Fadiman, Anne. 1997. The Spirit Catches You and You Fall Down: A Hmong Child, Her American
Doctors, and the Collision of Two Cultures. New York: The Noonday Press.
Helman, Cecil 1994. Third Edition. Culture, Health and Illness: an Introduction for Health
Professionals. Oxford: Butterworth Heinemann.

Hull, Cindy. 2004. Katun: A Twenty-Year Journey with the Maya. Belmont, CA: Thomson
Wadsworth.
Jordan, Brigitte. 1993. Birth in Four Cultures: A Crosscultural Investigation of Childbirth in
Yucatan, Holland, Sweden, and the United States. Prospect Heights, IL: Waveland Press.
34

McElroy, Ann and Patricia Townsend. 2004. Fourth Edition. Medical Anthropology in
Ecological Perspective. Boulder: Westview Press.
Quinlan, Marsha. 2004. From the Bush: The Front Line of Health Care in a Caribbean Village.
Belmont, CA: Thomson Wadsworth.

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Scheper-Hughes. 1998. Culture, Scarcity, and Maternal Thinking: Maternal Detachment and
Infant Survival in A Brazilian Shantytown. In Understanding and Applying Medical
Anthropology, edited by P. Brown, pp. 375-387. Mountain View, CA: Mayfield Publishing

RESOURCES ON THE INTERNET

A good collection of material is available on the Society for Medical Anthropologys website,
which is one of the sections of the American Anthropological Association.
http://www.medanthro.net/index.html

An independent collection of resources and news about medical anthropology can be found on
the Medical Anthropology Web.
http://www.medanth.org/
A website from Palomar College provides information on cross-cultural perspectives on illness,
curing, and culture specific diseases
http://anthro.palomar.edu/medical/default.htm
An extremely useful website about disease is the Center for Disease Control. Check out their AZ Index for information about a huge number of diseases
http://www.cdc.gov/index.htm
FILM RESOURCES
Jarmel, Marcia, and Ken Schneider. 2000. Born in the USA: A Documentary about Childbirth
in America. 58 min. PBS / Fanlight Productions.
McKee, Lauris. 1995. Birth and Belief in the Andes of Ecuador. 28 min. University of
California Extension. Berkeley.

Sharon, Douglas, and Richard Cowan. 1978. Eduardo the Healer. Penn State Media Sales.
Siegel, Taggart, and Jim McSilver. 2001. The Split Horn: The Life of a Hmong Shaman in
America. 58 min. San Francisco, CA: Alchemy Films.
Volkman, Toby. 1982. N!ai: The Story of a !Kung Woman. Cambridge: Documentary
Educational Resources.
REFERENCES CITED

Baer, Hans. 2003. Contributions to a Critical Analysis of Medical Pluralism: an Examination of

the Work of Libbet Crandon-Malamud. In Medical Pluralism in the Andes, edited by J. KossChioino, T. Leatherman, and C. Greenway, pp. 42-60. London and New York: Routledge Press.

35

Banks, Caroline. 1994. There is no Fat in Heaven: Religious Asceticism and the Meaning of
Anorexia Nervosa. Ethos 24(1): 107-135.
Bastien, Joseph. 2003. Sucking Blood or Snatching Fat: Chagas disease in Bolivia. In Medical
Pluralism in the Andes, edited by J. Koss-Chioino, T. Leatherman, and C. Greenway, pp. 166187. London: Routledge.

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Brown, Peter. 1998. Cultural Adaptations to Endemic Malaria. In Understanding and Applying
Medical Anthropology, edited by P. Brown, pp. 79-92. Mountain View, CA: Mayfield
Publishing.
Bryant, Carol, Kathleen DeWalt, Anita Courtney, and Jeffrey Schwartz. 2003. Second Edition.
The Cultural Feast: An Introduction to Food and Society. Belmont, CA: Thomson Wadsworth.

Cannon. W.B. 1942. Voodoo Death. American Anthropologist 44(2):169-181.

Caplan, Pat. 1997. Food, Health, and Identity. London and New York: Routledge.
Chagnon, Napoleon. 1992. Fourth Edition. Yanomam. Harcourt Brace.

Dettwyler, Katherine. 1992. The Biocultural Approach in Nutritional Anthropology: Case

Studies of Malnutrition. Medical Anthropology 15: 17-39.

Dettwyler, Katherine. 1994. Dancing Skeletons: Life and Death in West Africa. Long Grove,
Illinois: Waveland Press.

Etkin, Nina. 2001. Perspectives in Ethnopharmacology: Forging a Closer Link between

Bioscience and Traditional Empirical Knowledge. Journal of Ethnopharmacology 76:177-182.
Fadiman, Anne. 1997. The Spirit Catches You and You Fall Down: A Hmong Child, Her American
Doctors, and the Collision of Two Cultures. New York: The Noonday Press.
Farmer, Paul and Arthur Kleinman. 1998. AIDS as Human Suffering. In Understanding and
Applying Medical Anthropology, edited by P. Brown, pp. 333-342. Mountain View, CA:
Mayfield Publishing.

Foster, George 1967. Tzintzuntzan: Mexican Peasants in a Changing World. Boston: Little, Brown
and Company.
Fratkin, Eliot. 2004. Ariaal Pastoralists of Kenya: Studying Pastoralism, Drought, and
Development in Africas Arid Lands. Boston: Allyn and Bacon.
Hahn, Robert. 1998. The Nocebo Phenomenon: Concept, Evidence, and Implications for Public
Health. In Understanding and Applying Medical Anthropology, edited by P. Brown, pp. 138-143.
Mountain View, CA: Mayfield Publishing.

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Helman, Cecil 1994. Third Edition. Culture, Health and Illness: an Introduction for Health
Professionals. Oxford: Butterworth Heineman.
Jordan, Brigitte. 1993. Birth in Four Cultures: A Crosscultural Investigation of Childbirth in
Yucatan, Holland, Sweden, and the United States. Prospect Heights, IL: Waveland Press.
Lee, Richard. 2003. Third Edition. The Dobe Ju/hoansi. Wadsworth Publishing.

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Lloyd, G.E.R. 1964. The hot and the cold, the dry and the wet in Greek philosophy. Journal of
Hellenic Studies 84: 92-106.

Margolin, Malcolm. 1978. The Ohlone Way: Indian Life in the San Francisco-Monterey Bay Area.
Berkeley: Heyday Books.

Martorell, Reynaldo. 1989. Body Size, Adaptation and Function. Human Organization, 48 (1):
15-20.
McElroy, Ann and Patricia Townsend. 2004. Fourth Edition. Medical Anthropology in
Ecological Perspective. Boulder: Westview Press.

McKee, Lauris. 1995. Birth and Belief in the Andes of Ecuador. 28 min. University of California
Extension. Berkeley.
Oths, Kathryn. 2003. Setting it straight in the Andes: Musculoskeletal distress and the role of the
componedor. In Medical Pluralism in the Andes, edited by J. Koss-Chioino, T. Leatherman, and
C. Greenway, pp. 63-91. London: Routledge.
Romanucci-Ross, Lola. 1989. The Hierarchy of Resort in Curative Practices: the Admiralty
Islands. In Culture, Disease, and Healing: Studies in Medical Anthropology, edited by D.
Landy, pp. 481-7. Macmillan.
Salaman, Redcliffe. 1949. The History and Social Influence of the Potato. Cambridge:
Cambridge University Press.

Scheper-Hughes. 1998. Culture, Scarcity, and Maternal Thinking: Maternal Detachment and
Infant Survival in a Brazilian Shantytown. In Understanding and Applying Medical
Anthropology, edited by P. Brown, pp. 375-387. Mountain View, CA: Mayfield Publishing.

Schieffelin, Edward. 1976. I'm Sorry Brother, I Don't Eat That. In The Sorrow of the Lonely
and the Burning of the Dancers, pp. 46-72. New York: St. Martin's Press.
Shostak. Marjorie. 1981. Nisa: The Life and Words of a !Kung Woman. Cambridge: Harvard
University Press.

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