Green (2004) An Ethnography of Nonadherence: Culture, Poverty and Tuberculosis in Urban Bolivia

Green. 2004. An Ethnography of Nonadherence: Culture, Poverty and Tuberculosis in Urban Bolivia. Culture, Medicine and Psychiatry 28: 401-425.
Working with five patients on a clinic in a suburb neighborhood in La Paz, Bolivia Green tries to understand how Aymara people (before the very radical changes brought by Evo Morales) although confident of biomedical diagnosis and treatment of Tuberculosis could not keep up with the long treatment due to structural poverty and lack of government aid. Normally a TB treatment would take up to 6-8 months with the first 2 having to go everyday to the hospital for the medicines. In the last decades a specific form of treatment arise, a short-course directly observed therapy (DOTS) in which patients must be present every day for as long as 4 to 6 weeks (then would be once every week) in order to take their pills. TB is the first cause of death in adults in Latin America, but in Bolivia within indigenous people the rate is 5 to 8 times higher than the national average. Nonadherence is considered when a patient doesn’t or can’t finish his or her treatment. At least four causes explain the widespread of TB, the correlation with HIV/AIDS, the relation between TB and adverse social conditions, the rise of drug resistant and multi-drug resistant traits due to nonadherence to treatment, and the incessant risk of contagion of inadequately treated patients. These four causes are enhanced by four more common factors: the blaming on the patient; the patient’s psychological structure; demographic factors such as gender, sex or income; and cultural and linguistic differences produced by the lack of knowledge about the local culture. Citing Farmer, Green considers that the “structural violence” is what can explicate how “poor adherence within an ethnically marginal group is often better explained by economic or political constraints than by folk-cultural constraints” (403). Some of this socio-economic-political constrains are “structural variables such as geographic and temporal availability of health care, hidden costs of treatment, and quality of available care” (404). The informants have to make a big effort to go everyday to the clinic to receive the medication, sometimes they could not afford to pay the bus so they would walk for 1 or 2 hours each way to the clinic and back home. They also have difficulties to keep up their job if they have one, or to look for one if they were unemployed, because going to the clinic would take a big chunk of time (they would be waiting and waiting for a whole morning). So when they could not carry on with the treatment for any reason (always very logical) then they were afraid of the reprimands by the doctors and social workers who would treat them, sometimes, discriminatorily. If social workers would complain that patient are putting their life in risk, patients would say that they need to support their families and can’t afford not to work. Although patients do feel sometimes that guilty for having “abandoned” treatment and this further complicate the decision to go back to the TB control program. All the patients were using both traditional and biomedical medicine, and they all agree that for TB biomedicine was better suited to cure it instead of the palliative treatment provided by traditional healers. I think this article is interesting to see how patients were using multiple forms of care and cure, and although they wanted to be treated by biomedicine for curing TB, they could not keep up with the treatment due to structural constrains such as hidden costs of the treatment (transport and additional costs such as X-Rays) and professional discrimination against Aymara population.

Mysyk (1998) Susto: An Illness of the Poor.

Mysyk, Avis. 1998. Susto: An Illness of the Poor. Dialectical Anthropology. 23(2): 187-202.

In Latin America the “folk illness” commonly known as “susto”, also called as “pasmo”, “espanto” and “perdida de la sombra” can be defined as “soul (or vital force) loss through magical fright”. The associated symptoms are usually: listlessness, weakness, loss of appetite, lost of interest in personal appearance, restlessness during sleep, and often more acute symptoms such as fever, vomiting, and diarrhea and may even cause death. The basic pattern to treat susto was to recognize the event that caused the fright, to search and find the lost soul (vital force) and eventually its re-appropriation into the body. Mysyk find three common explanations for susto, which were reciprocally exclusive: physiological (hypoglycemia), psychological (hysterical-anxiety disorder), and social (incapability to live up to social relations).

The main goal of this article is to reconsider who suffers and why. Mysyk wants to highlights the relationship between susto and class situation, which according to him has been almost ignored. He traces the Nahua explanation of loss of the vital force or tonalli, which could be lost or harmed by witchcraft. Then he refers to Rubel who finds that susto occurs in social situations which people sense as stressful, situations that are intracultural and intrasocietal, stressful situations that depend on the significance of each particular task and the failure to achieve it in each society, and therefore individual’s personality, his/her health status, and society are all implicated in the production of susto. Then, O’Nell found two types of fright: a “rationalized” connected with nonhumans, which has a slow symptomatology and the “precipitating” connected with humans, which has a fast symptomatology, and the author identifies a symbolic reflection of the “victim’s” stress pattern.

But for Mysyk, it is not clear if O’Nell consulted with the “victims” if there is actually a symbolic relation between the frightening event and the stress patterns. One could say that poor people and low class conditions are traversed by violence and constant forms of fear (Green would call it “fear as everyday life”), so the question is way certain people in these types of conditions develop susto? For Mysyk is clear that class position and cultural marginality and social mobility are central in the explanation of susto. But “susto” is embedded in a continuum from indigenous people that treat it with indigenous healers to ladinos that see it only as a term (this is what Mysyk says) that refers to intestinal parasites and which are treated with biomedical medicine. He then says that susto is “symbolical statement of an individual’s position in the community, whether self- or other-perceived” (195) and it implies different “message” depending the class position and social mobility; for instance, in case of mestizos in Bolivia the symbolic statement is their “downward mobility”.

For Mysik the corollary is that susto is the result of social conditions that turn unmanageable by the poor people, mainly poor peasants and landless laborers. What strikes my attention is that Mysyk is fast to dismiss explanations centered in role stress to put his explanation of class position but I still cannot understand what he means by class position. It seems that structural-functional ideas of (mis)adaptation are brought into the discussion without explicitly referred to them.

Weller et al. (2002) Regional Variation in Latino Descriptions of Susto

Susan Weller et al. 2002. Regional Variation in Latino Descriptions of Susto. Culture, Medicine and Psychiatry 26:449-472.

In the literature Susto is considered to be cause by a frightening event (specific in time) involving another person, an animal, a spirit, or a situation. It can cause either a displace of “an immaterial substance, an essence” (Rubel et al. 1984: 8, cited in Weller et al. 2002: 449) from the “body” that would cause the “victim” to become ill, but in other cases (which they don’t consider so much) susto can be caused not by a subtraction of vital force but by addition of vital force, in this case by an introduction of a spirit into the body (something very frequent in shamanic societies in which the shaman has to make certain rituals to expel the intruder). In the literature it was also common to find susto associated with a higher risk of anemia and parasitic infections, and overall a higher mortality rate. The key point when considering the “frightening event” is that it has a negative effect in interpersonal relationships. Stop here. A brief note: can we be very sure that the event that causes susto has an effect in interpersonal relationship? Could it not be also a cause in itself? In the classic anthropological literature in the Chaco region, for instance with Toba people, in many cases the (negative) interpersonal relationships were the cause of conflicts, that would eventually lead to people making harm one another via shamans and so loosing one of their many souls, and therefore causing susto. So here the effect is susto and the cause is the change in social relationships not the other way around.

But Weller et al do not consider this. They cite Logan (1979) who refers to competency for resources as a cause for sorcery, and the need for a healer to cure this “supernatural” causes of frightening, but then during their own research they give less weight in their analysis. They consider more the situation in which the “essence” is lost, and there is a subtraction of vital force. Their focus is more on “community descriptions of susto”. And they center their research in three “communities”, one in Guatemala, another in Mexico (although Guadalajara is not precisely a small community, it’s a 3M city), and the last in a small town in Texas, US. They develop a 127-question questionnaire. Another brief note: Why so many question? Who would answer them? The interesting thing about their inclusion criteria is that people have to know and believe in the existence of susto. In the US they chose people self-identified as having Mexican descent, and I wonder why? Non-Mexican people cannot have susto?
In only one point the researchers mentioned non-traditional, they put it as “more contemporary”, causes such as use of drugs in Mexico. But besides this there is still a big divide between “culture-bounded” syndrome such as susto, and “more contemporary” types of illness, it seems that susto is seen as a traditional believe that people somatized but it is not actually “true”. I wonder which would be the difference in approaching and understanding susto if researchers would actually know, believe, perceive, and experience it?