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As they forded the river below their ranch, the swift current swept the father off his feet. He saved himself only by seizing an overhanging vine. The daughter, standing on the bank, watched in alarm. The father reports of his daughter's reaction, as follows: "In fifteen days she was very sick with susto, but I didn't suffer anything. It... is very interesting: Some people become ill with susto and others do not even when they suffer the same experience."
As another informant put it:
It's this way... the water contains a being which is its virtud, its force or strength, the same as the earth, the woods, the high mountains, and everything. We say that that force steals the strength of humans. It steals our strength and weakens it. To keep this from happening, one must speak to the earth [or water], one must take this action... so that our spirit does not remain there.
We hope both to provide new, more relativistic understandings of what it means "to be ill" in other cultures, and to acquire some insight about ourselves. There surely remain few redoubts of ethnocentrism as formidable as explanations of disease causation and the management of illness.
All societies have been obliged to develop procedures to prevent and treat illnesses. These procedures constitute significant dimensions of a culture and are sensitive to social values: "... it is the prevailing philosophic concepts of man which influence his medicine most profoundly" (Pelligrino 1963:10).
We initiated our multidisciplinary investigation of susto (the word itself means fright) with the assumption that we could not understand illness across cultures on the basis of premises produced by our own (Kleinman 1980:378). Consequently, we defined illness as "syndromes from which members of a particular group claim to suffer and for which their culture provides an etiology, a diagnosis, preventive measures, and regimens of healing" (Rubel 1964:268). We sought to build on earlier studies (particularly the works of Bahr et al. 1974; Fabrega and Silver 1973; Frake 1961; Kleinman 1973; G. Lewis 1975; Metzger and Williams 1963) in which the researchers had recorded and scrutinized the manner in which different peoples think about illness. We felt we could not hope to comprehend health and illness anywhere until freed of our own ethnocentrism.
One of the most important goals of anthropological research has been to demonstrate how health understandings and practices elucidate the dominant values, beliefs, and normative expectations of a society and serve as a mirror of the affective qualities of social relationships. Early anthropologists described health institutions much as they discussed the cultural patterns revealed by observations of the family, government, and religion. This tradition persists, for example, in a recent analysis of the rural Costa Rican condition known as nervios. Barlett and Low sort out the manifestations of this problem to establish a relationship between the complaint and other dimensions of the lives of these people. They conclude that "the examples of nervios sufferers seem not only to illuminate a complex culture-specific complaint, but also to reveal the most fundamental expectations of life in rural Costa Rica" (1980:554). Morsy (1978) uses another culture-bound syndrome-uzr -to elucidate the patterns of social power relationships among Egyptian villagers and goes on to show how her results permit us to better understand the bonds between relatively powerless villages and the central government.
These and other studies have helped demonstrate the functional interrelationship that obtains between health concerns and other value or belief constructs-for example, the relationship between the visitation of illness in a family and a member's having transgressed social norms (Rubel 1966; Vogt 1969:371-374). Marwick's (1965) interpretation of a case of illness as precipitating the fission of subgroups from a parent kinship unit when their social relationships have become insupportable is another case in point. However, Comaroff (1978) has cautioned that the tightness of the researchers' integration of a society's understandings about health with other concepts of its social order represents the analytic efforts of the former more than the thinking of the latter.
In other accounts, researchers have suggested that therapeutic rituals exploit the opportunity presented by a patient's difficulties to resolve interpersonal and intergroup problems and restore social unity (Turner 1967:361-362). In a somewhat different vein, Levi-Strauss considered the trial of a Zuni youth accused of causing a friend's illness as providing the group an opportunity to reaffirm its confidence in the cultural system at large (1963:172-175).
Some studies of folk illnesses have simply assumed that they are psychiatric in nature, ignoring the contribution of organic problems to these complaints even when organic signs and symptoms were observable (Kiev 1968). This "psychologizing" of folk illness has exacerbated the difficulties of separating disease processes from the cultural response to them. Because the presentation of emotional difficulties is even more stylized than presentation of an organic problem, the task of developing cross-cultural evidence about psychological disease conditions has been made the more difficult (Fabrega 1974:40; G. Lewis 1975:93-94; Kleinman 1973:209).
Studies that emphasize traditional healing rituals generally fail to report whether or not the patient recovered or even whether symptoms were alleviated. They sometimes imply that the ritual was efficacious, but present no supporting evidence. For example, Klein, discussing treatments for susto, assures the reader that they are efficacious: "... recognizing the cultural and psychological bases for susto cures should not belittle the physiological effectiveness of the methods employed; all three dimensions interact in healing to combat the symptoms, which are alleviated in most cases" (Klein 1976:26, emphasis added). Although this claim is plausible, no data to support it are presented. Similar unsupported claims abound in the literature. This romantic idealization of traditional healing, which reverses the more common ethnocentric view, only adds to the difficulty of assessing any kind of healing in unfamiliar cultural settings (Donabedian 1966). Kleinman and Sung reported, in 1979, some of the factors that complicate such an effort. They undertook assessments of patients' symptoms two months after initial treatment at a shrine in Taiwan. Although the patients generally reported themselves to be either cured or significantly improved, the investigators failed to "find conclusive evidence to show that a single case of biological-based disease was effectively treated by the tang-ki's therapy alone." Kleinman and Sung suggest that, prior to an assessment of healing, it is prudent to comprehend all the dimensions of the problems of which patients complain. We are not denying the efficacy of noncosmopolitan systems of healing, but we are recommending that traditional practices be approached with more rigor than has been common (see Finkler 1980).
The extent to which disease is molded by culture remains one of the more provocative issues in anthropology. For instance, the chronic disease commonly known as arthritis or rheumatism and technically recognized as degenerative joint disease appears mainly among older individuals or as a sequel to injuries of a joint. It is found among cultural groups in diverse environments (Lawrence 1966:755-756). Radiological assessments portray degenerating joints, and patients indicate pain on movement or pressure applied to a joint, and complain of weakness. Swelling and enlargements, deformity, atrophy, and shortening of the muscles and abnormalities in the affected skin are easily noted by the trained eye (Edwards 1966:747). With such objective evidence, it is not unreasonable to expect victims to express their discomfort similarly. However, reports of this illness vary systematically among culturally different populations, and even Americans of similar ethnic background have learned to respond differently to it when they are members of different social classes. (Elder and Acheson 1970; Koos 1954). Other reports have shown that Americans complaining of ear, nose, and throat problems systematically emphasize different symptoms depending on their ethnic backgrounds (Zola 1966). Furthermore, even patients' complaints of pain vary according to ethnic group membership (Zborowski 1952). It is clear from this evidence that the objective signs of a given disease process may be molded by the culture and experience of the victim. The distinction between the invariant objective indications of a sickness-the disease-and the way in which the patient describes the problem-the illness-(Eisenberg 1977) is especially important when the complaint is unfamiliar to the researcher. Efforts to "domesticate" exotic health conditions to make them more understandable are described as using the concepts of biomedicine as if they formed a Procrustean bed, contributing to "the degradation of a productive scientific model into a dogma" (Engel 1979:257). The extent to which culture provides the form in which disease becomes illness and then sickness is one of the more fascinating inquiries in cross-cultural research. In a discussion of culture-bound syndromes, Kennedy comments that "most modern scholars tend toward the opinion that these exotic maladies are not clinically distinct syndromes, but are simply the old familiar psychiatric syndromes of the West called by different names and shaped by different cultures" (1973:1152). We disagree with these scholars; our investigation of susto demonstrates how cultural and disease processes interact to form an entity unfamiliar to cosmopolitan medicine.
The cross-cultural study of susto is best approached by fixing attention on the ways in which the patient and his or her family describe the condition: The victim is (1) restless during sleep and (2) otherwise listless, debilitated, depressed, and indifferent to food and to dress and personal hygiene (Sal y Rosas 1958; Gillin 1945; Rubel 1964; Logan 1979; cf. Tousignant 1979:153).
A striking discovery is that this condition is not culture-bound. That is, it is not restricted to a population speaking a distinctive language, or to a singular cultural background. It is found in many cultural groups in North and South America. It is reported among Mexican Americans in the United States (Clark 1959:155-158; Mull and Mull 1981; Martinez and Martin 1966; Rubel 1960; Saunders 1954), in Peru (Gillin 1947; Sal y Rosas 1958; Chiappe Costa 1979; Bolton 1981), in Argentina (Palma 1973; Palma and Torres Vildoza 1974:164, 171), in Colombia (León 1963; Seijas 1972), among Guatemalan groups (Gillin 1945; Adams and Rubel 1967; Logan 1979), and throughout Mexico (Adams and Rubel 1967; O'Nell and Selby 1968; Vogt 1969:370). Moreover, similarly characterized conditions associated with fright are reported in the literature from the Philippines, India, The People's Republic of China, and Taiwan (Hart 1969).
Focusing on the names given to the condition, which is also known locally as pasmo, tierra, espanto, and perdida de la sombra, makes it easy to be distracted from the commonalities that exist (Seijas 1972, 1973; O'Nell 1970; Rubel 1970) and, indeed, may sometimes temporarily obscure real differences. In research among the Sibundoy of Colombia, Seijas (1972:177) was eventually obliged to conclude that what they called susto was not the condition described in these pages, but an assortment of pediatric conditions and a catch-all category of adult illnesses for which more usual explanations were socially inappropriate. We use the term susto here only when it refers to a cohering set of characteristics that recurs across groups. We fix our attention on a phenomenon, a reality, reported by groups that differ in language and culture. Doing so makes possible comparisons and replication of results.
Rejecting any correlation between what our informants referred to as susto and diseases or functional disorders described in textbooks of cosmopolitan medicine, we began with the assumption that any equivalence that might be established should be based on empirical descriptions of the folk condition. On this matter Comaroff (1978:249) has been helpful:
Anthropologists have been critical of the indiscriminate application of the bio-medical paradigm to the study of actual medical systems, for it presupposes pre-emptive definitions of relevance. The perspective of scientific medicine is expressed by means of conceptual categories which may well be inappropriate in other medical systems; as a base-line for comparison, it might obscure their particular relevance.
In the Costa Rican research mentioned earlier, Barlett and Low (1980), apparently sharing this viewpoint, prudently refrain from premature biomedical identification of nervios. Complaints of nervios, they report, are regularly attended to by physicians even though they show no equivalence to the kinds of conditions physicians are trained to cure. These researchers record a wide array of symptoms affecting people of both sexes and all ages, with much higher prevalence among two groups-those 19 years of age and older, and women. With such a valuable baseline description in hand, this problem becomes amenable to more finely honed inquiries.
Simons's (1980) work on latah, which afflicts large numbers of people in Malaysia and Indonesia and has close counterparts in the Philippines, Taiwan, Thailand, and Burma, is similarly free of a priori assumptions about equivalents in cosmopolitan medicine. Simons finds that most victims of latah are women, tend to be in mid-life when the experience occurs for the first time, and are of relatively low social status. The person suffering from latah typically responds to a startling stimulus with an exaggerated start, often throwing or dropping an object and uttering words ordinarily inappropriate in conversation. Both those studies indicate the fruitfulness of a careful search for explanations in the interaction among biological, emotional, and cultural factors rather than a focus on the pathologies described in textbooks of medicine.
Excerpted from Susto by Arthur J. Rubel Carl W. O'Nell Rolando Collado-Ardon Copyright © 1984 by Arthur J. Rubel, Carl W. O'Nell, and Rolando Collado-Ardon. Excerpted by permission.
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|1||Introduction to Susto||1|
|3||Description of Susto||30|
|4||Sampling of Groups||49|
|Methods of Testing the Hypotheses||53|
|Levels of Social Stress||55|
|Levels of Psychiatric Impairment||60|
|Levels of Organic Disease||63|
|Indications of Social Stress||71|
|Indications of Psychiatric Impairment||73|
|Indications of Disease||80|
|Classes of Diseases||87|
|Results of Laboratory Tests||98|
|Gravity and Severity||100|
|6||Interrelationships Among Results||112|
|Implications of This Study||120|
|22-Item Screening Score for Measuring Psychiatric Impairment (Modified)||125|
|Instructions for Scoring the 22-Item Screening Score Responses||125|
|Social Factors Questionnaire||127|
|Scoring Instructions for the Social Factors Questionnaire for Males||133|
|Score Sheet for Social Factors Questionnaire--Males||141|
|Scoring Instructions for the Social Factors Questionnaire for Females||146|
|Score Sheet for Social Factors Questionnaire--Females||152|
|Instructions for Scoring Gravity and Severity||160|
|Score Sheet for Measures of Severity and Gravity||167|