4 – Sociocultural Disease Clusters

SocioculturalSocioeconomicHealth_SSH

The woman in the above picture is Ayaan Hirsi Ali, who wrote a book about her infibulation experiences and who has helped to improve social awareness about this controversial traditional African Muslim practice, considered cruel by most governments, societies, and cultures.

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Focus on an Urban Area —

Numbers of children less than 5 years of age with a history of infibulation

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Sociocultural diseases

Sociocultural diseases are of four types:

  • Culturally-born by means of ecology and genetics
  • Culturally-bound by means of behavior and cultural belief systems
  • Culturally-linked by means of genetics and heritage combined with cultural behaviors
  • Culturally-influenced, by means of culturally-linked causative factors that are not necessarily induced or caused due to a specific culture

A.  Culturally-born diseases by means of ecology and genetics deal with the traditional Darwinian-Mendelian interpretation of disease patterns, which states that depending upon how we are exposed to our environment, and the make up of our heritage or genetic lineage, we may or may not become ill due to a particular exposure to certain stimuli.  These stimuli can be such things as microorganisms living in the local ecosystem or specific environmental features like humidity, excessive heat, etc.  The types of diseases or conditions referred to by this category include foreign born diseases, especially infectious diseases, and some genetic traits or conditions.

B.  Culturally-bound syndromes or diseases are sociologically defined actions and reactions that related to a person’s health.  Due to the social nature of this disease, condition or syndrome, social paradigms play a heavy role in defining these conditions.  These diseases are mostly psychological and behavioral or even psychiatric in nature.  They can have physiological manifestations, but such manifestations occur mostly as secondary ore even tertiary diagnostic features and may play little role in the long term outcome.

aging, health, and takotsubo

C.  Culturally-linked conditions or diseases are somehow related to a specific cultural group for both physiological-anatomical and psychological-behavioral reasons.  These diseases have both a physical manifestation that results in a physical onset of illness, but related to the severity and perhaps cause and onset of this condition are certain personal behavioral and psychological states, which are usually best understood when interpreted in light of the preceding events.  Some researchers like to label these as genetic traits, which may in part be true.  But there is a combination of physiological-anatomical features and psychological or behavioral features (more so than psychiatric) that exert major influences on these conditions.  They can often be linked to physical features, which in turn are typically assigned some sort of genetic causality.

Takotsubo is an excellent example of a culturally-linked diagnosis.  It impacts primarily Asian people in their older years.  It also demonstrates a very unique relationship to age and gender in that it impacts women a lot more than men.  It is a heart condition that results in death due to health disease, but the underlying cause for it is probably emotional, and which for some reason is found in Asiatic culture but to date hasn’t been diagnosed much in American culture, unless of course those Americans of of the appropriate heritage and descent.

The following link is to a map video that demonstrates its distribution across the country.

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D.  Culturally-influenced disease states are those in which culture plays a heavy role in their incidence and prevalence, and the lifespan of those diagnosed with these states.  Cultural influences the severity and personal and social reactions to the diagnosis, but for the most part other more predictable biological or otherwise physical qualities help to define the outcomes of these patients.  These diseases are common to most or all cultures, although epidemiological transition also plays a role in when, where and how such new additions to a group of people may or may not ensue.  For example, the Inuit in 1850 lack diabetes as a chronic disease, but following the establishment of the Fort in Hudson’s Bay and their conversion to Fort-based food products, the onset of diabetes ensued for the first time, around 1880.  Likewise, indigenous groups removing to more heavily populated urban settings display asthma as a new chronic disease in need of improved management. We’d expect to see fibromyalgia develop in certain sociocultural groups due to assimilation/acculturation processes.

FINAL NOTE.  Cultural diseases

happen due to a mixture of heredity, living styles, beliefs and social expectations, and traditional human ecology.  Examples of the first type of disease noted above are common sense.  The second type of disease is an environmentally-induced state, of a reactive nature or of an interactive nature; the important skillset required here is distinguishing physical symptomatology from environmental versus somatic versus psychological cause.   Reactive nature diseases are due to our reactions to our environment, mostly anatomically and physically.  Interactive diseases are those that require nature and our relationship with nature to exist, such as bacterial diseases, zoonotic diseases, etc.

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Sociocultural Disease Analysis

Sociocultural disease analysis is usually a review of diseases linked to specific cultural or ethnic groups, but these groups may include some socioeconomic status groups as well.  But this term is used mostly to review cultural disease patterns, with special attention paid to specific groups with culturally related needs.

This method was developed in order to produce an end product that tells us about the impacts culture have on the local environment and human ecological disease settings.

Examples of its applications would include an medical anthropological approach to scoring the health risk of a particular ethnic group.

Some of these examples now follow:

Part 1.  Origins

The following are the results of my first pass through the ICDs, which focused on ICDS in relation to place, ecology and culture.  This work focused on the Index-Catalogue of the Surgeon General’s Office, which was published from about 1865 to 1918.  This work was an incredibly extensive task that took me several years, on and off, but was worth it for it resulted in my ordering more than 6000 articles published between 1800 and 1930, in several languages, of which more than half were obtained.  These are the earliest and most important articles ever published in medical geography.

I related the information in these articles to the standard ICD data from 2003 to present. The bulk of my analysis of my findings took place in 2003 and 2004.  The population health statistics map production began in 2004/5 (winter), with the first innovative products in whitepaper, graphical and chart form displayed beginning in 2005.

My very first year of map production reviewed about 2000 ICD9 groups and single ICDs, with an emphasis on the most underrepresented ICDs for the time, the most socioculturally important conditions/diagnoses/etc. and/or those demonstrating significant presence in the news such as child abuse, child abandonment, school violence, explosive personality disorder, hanta virus spread.  Of the 2000+ reviewed, between 150 and 350 of these ICDs, depending upon the place and period, had spatial, temporal, international, cultural and historical significance.

These data were then reviewed separately as maps, and then merged into groups, mostly by continent or isolated island communities.  These groups were defined based upon Cultural or Region in the world, were worldwide in their focus, and queried to produce maps of how ICDs from specific parts of the world seem to flow into and through the United States.

Most of these maps have two versions (mostly just the second version is presented here).  The initial maps are of diseases that are spread by vector, animal/livestock host, and contagious human-born elements, the second are diseases from other countries that are not necessarily transmittable.  Place-specific diseases were reviewed, not widely dispersed diseases like influenza strains, or certain intestinal worm diseases once considered regional, but now globally diffuse.  The following are the analyses of these “imported diseases.”

All imports   Japan    Mex/S Amer   Aust    USSR    Asia    Africa 

Total Disease Influx or Importation, by Major International Routes and Regions (there are two versions of these–version 1 measures influx of principal diseases indicative  of primary migration routes, v2 adds other ICDs linked mostly to the country or region evaluated.  A full collection of these maps is scheduled for posting later this year.  Some v2 maps have close-ups of high density urban areas.)

.ForeignBornDiseasePenetration-Regions_3+3imgs_salmon

The History of a Disease Pattern

The American Indian rarely had diabetes or obesity in the mid 19th century.  This is because of the traditional lifestyle, which included periods of starvation due to droughts, social unrest, poor climates and the like, but also included the constant need for the people to move to new locations, engage in physically enduring outdoor activities like hunting, travelling between social settings, engaging in periods of social interaction related to trade and religion.

Between 1860 and 1870, Hudson’s Bay Company began a series of programs for the Canadian Inuit that involved supplying them with lard, grains, and a variety of army related food supplies.  By 1880, one of the first articles ever published on a growing Native American diabetes issue was published.  This article would be followed by reviews and articles on American Indians residing in United States territories.  The Navajo were the first tribe to be researched in detail regarding their health and activities.  In the early 1900s, there were no true indicators of any problems linked to diabetes, or its related heart diseases and obesity.  But this was the first time significant focus was placed upon this group and its slow assimilation-acculturation like activities.

To term these changes “assimilation” are only half-truths in fact.  The assimilations that were discussed in the literature were actually changes  forced upon these people due to the ever changing land use patterns the government was supporting.  Between 1910 and 1930 for example, a number of articles published about Native American health in the U.S. made note of their peculiar physiological findings at times, in particular the athletes heart or bradycardia prevailed in young men often engaged in long-winded outdoor activities such as running between reservation settings for the purposes of communication.  By the 1920s, physicians were marvelling at the health of these young runners, and this gave rise to further reviews of Native American health and longevity by early medical anthropologists like Alec Hrdlicka.

The belief for the time was that Natives did have a particular aspect to their lifestyle and genetics that was in favor of longevity.  But the high frequency of infectious diseases and other stresses on life and survival minimized the rates of elders living to a very old age.  Nevertheless, some elders who were still around seemed to outlive the health elders of other white American Saxon Protestant groups, giving way to a number of eugenics related ideologies  and popularizing the teachings of certain scientists devoted to this field of science.

The came World War II and the association of eugenics with Adolph Hitler’s philosophy.  This led to a rapid reduction use for this term over the decades to follow.  As assimilation processes changed and their followers grew in numbers within certain settings, we say diseases set in that were most indicative of this transculturation process.  The most prominent of these changes was the increase of diabetes rates in most of the Native American cultures.  From the 1950s through to the 1970s, this led many to research these disease changes, and by the 1980s the New World Disease concept was born by Medical Anthropologists.  What once called a “Survival Gene” by Hrdlicka (true spelling) and others was now rapidly being interpreted as a negative trait according to these new concepts being taught.

Between 1980 and 1995, the New World Syndrome was redefined, as a variation on an older disease concept already out there.  The notion of certain endocrine related somatic and metabolic disorders was linked to the New World Syndrome.  As similar findings were seen as well in a number of indigenous cultures across to Circumpolar region, and within small subgroups of cultures in parts of Western Europe due to genetic based passage of these metabolism-linked differences, the term metabolic syndrome stuck, and this current physiological, health related illness-related phenomenon has pretty much been culturally defined as metabolic syndrome, and is associated with onset of obesity, hypertension, hyperlipidemia and related heart diseases, and ultimately diabetes as one ages.

What was once considered the gift of being allowed to grow old in the Native American tradition, was now culturally redefined as a chronic disease.  The athlete’s heart syndrome was changed into an unhealthy state, rarely seen except in athletes, to a condition replaced by the onset of ill-health.  The acculturation of certain groups of Native Americans only added to this.

In the 1790s for example, the consumption of fat-fried dough was introduced to Indians in and around Hudson’s bay along its western shores.  The dough fried snackfoods sold at Indian gathers is by no means traditional Indian food.  The rising of dough was neither a traditional indigenous way for North American natives to live, nor even was it a part of Middle American cultural foodways.  The processing of cassava flour by pounding it into a mash on a stoney surface barely involved anything such as the use of yeast to raise the bread into an airy foodstuff.  Nor was enough oil ever pressed from any foodplants in order to deep fry that cassava recipe.  Both rising flour and deep fat frying were by no means Native American tradition food preparation habits.

Sociocultural diseases are those which develop due to sociocultural behaviors.  They can sometimes be traditionally induced, based upon traditional logic and philosophy such as the possession of one’s body by a diabolo (traditional Mex.-Aztec) or the onset of seizures due to invasion by a past ancestral spirit (Navajo).   Sociocultural diseases can also be a by-product of assimilation, acculturation, or simple a culture’s self-defined decision made to live another lifestyle.

The Pima Indian morbid obesity problem for example is a little bit of both.  It is the consequence of a people taking on sheep farming practices instead of living an unstable nomadic life, but also a consequence of the acculturation that comes from this change in life style, in a modern western social setting.  The consumption of fried dough with fast food burgers, shakes and soda, to name a few examples of traditional foodways change, accompanied by reductions in wild food plants (or farmed) and the consumption of fish oils, eel oil (which is healthier than the fish oil) and the replacement of wild fish with farmed and store bought fish, only aid further in this assimilation or transformation process.

The numerous medical anthropology writings focused on disease and cultural transitions provide important details about this part of medical history and epidemiological change that we have yet to develop a full understanding of.  A number of the analyses I made were developed based upon the studies of mine that led to these conclusions back in the 1990s.

The following few links or note in this section are devoted to this particular historical epidemiological aspect of spatio-temporal health and disease patterns.

[Insert examples, links, etc.]

Part 2.

Socioculturally-born Infectious Disease as a Behavior

Immnztns_Polio-variola-smallpox

Example 1.  Childhood Immunization Refusals

Refusal to have your child vaccinated is a very culturally-defined practiced.  Although covered extensively on another page, it fits into this category due to its social causes.  There are several things to notice about this particular health care behavior–first, it occurs in a specific region due to a specific cultural belief system common to that area, and second, it involves enough people to have this group stand out as an exception to social public health behaviors and the most widely accepted political practices, but not enough to influence the biology and ecology of the disease itself.  Even though refusal to immunize a child peaks in the Pacific Northwest, this is also one of the regions where more than 95% of the children are successfully, completely vaccinated according to HEDIS standards.

With the two above polio maps, we see immunization refusals peaking in the Northwest and the polio disease itself peaking around the Great Lakes.  This refusal pattern repeats for variola vaccine, but the disease it serves to prevent, small pox, doesn’t peak in that area due to the overall success of the immunization program.

The fact that a secondary peak also exists in the Chicago area for variola vaccine, and in the Denver area (probably due to refusals in Boulder), also have no impact on the distribution of small pox cases.  This demonstrates the value of the herding effect–a disease philosophy which states that in theory, an infectious disease will fail to produce a full-fledged epidemic if enough of the crowd behave correctly by engaging in the right prevention activities.

Part 2.  Sociocultural Diseases as a Public Health Issue

Example 2.  Tuberculosis.

TB-ip_CongenitalTb-N

If we apply some of the above philosophy into tuberculosis, we get a better understanding of this aspect of human behavior as a culturally-related public health issue.  The primary risk of tuberculosis was reduced greatly by the reduction in Tb cases between the late 1950s and the 1980s.  During the 1970s, due to the Vietnam war, we had a large influx of South Vietnamese, Laotian, and Cambodian who fled their countries to become citizens of the United States.  Members of the elderly population were still carrying tuberculosis.  This resulted in a public health program in 1979 that successfully reduced this problem in the impacted urban settings.

These cases also demonstrated the problems in-migration causes for immunizable disease patterns than have been almost totally extinguished from the United States.  The cases of congenital Tb represent missed opportunities, since the mother bearing the child wasn’t adequately vaccinated.  Congenital Tb (right map) appears to be very much population based with its distributions.  It demonstrated peaks along the megalopolis of the eastern coastline and a ridge along the central midwestern region.

The peaks on the west coast are in Seattle, Portland and San Francisco areas, with a minor peak in Salt Lake City.   These peaks represent the result of social behaviors linked to alternative medical philosophy, in particular the influences of religious philosophy and beliefs on medicine and peoples’ engagement in health care visits and preventive care practices.

Tb and Tb-immunization are influenced by different sociocultural histories and behaviors than the childhood immunization programs activities.  As a result, the risk groups are modified and distributions also impacted.  There are two events controlling congenital tuberculosis spatial distributions–the standard population density behavior, in which in-migration and failure to receive timely treatment are involved, along with the socioculturally defined anti-establishment attitudes projected as social behaviors engaged in within certain portions of the west coast urban settings.  Overall, Tb rates are highest within the Eastern states.  Passing on this disease to a fetus is the result of a more culturally-derived attitude and behavioral event.

Part 3.  Sociocultural Behavior as a Moral Issue

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Final Part: More Examples of NPHG Applied to Socoicultural Health Surveillance

Apply the above to the following sociocultural disease videos developed for the US.  Identify possible country or place of origin, possibly in-migration pattern or route from abroad when applicable, and determine the most active route taken by carriers, hosts, vectors or ther sources

Sociocultural Physical Conditions or Diseases

The following are the kinds of questions that can be answered based on the above maps produced (pretend you’re a student for a moment):

  1. Which disease(s) is/are native to the U.S.? (name 4)
  2. Which are most linked to genetics? (name 3)
  3. Which one disease is native to the North American continental, for now?
  4. Pick three of the above and define the possible in-migration route via Florida or the Southeast? the Pacific NW? the Tex-Mex border?
  5. Just seven of the above constitute possible intrusion and national security related examples.  Try to define five of these.  Which are the the top two in descending order of importance?
  6. If you were told that one of the above is in high numbers on the SW shores, which one is it most likely to be?  Which one currently demonstrates this tendency more than the rest?
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