YEARBOOK O F PHYSICAL ANTHROPOLOGY 27:215-227 (1984) Biomedical Anthropology: An Emerging Synthesis in Anthropology FRANCIS E. JOHNSTON AND SETHA M. LOW Departments ofAnthropology (FE.J.) and Anthropology and Landscape Architecture and Regional Planning (S.M.L.), University of Pennsylvania, Philadelphia, Pennsylvania 19104 KEY WORDS Disease, Medical anthropology, Adaptation, Nutritional anthropology, Human ecology ABSTRACT Biomedical anthropology is a newly emerging focus within anthropology, combining concepts of physical anthropology and medical anthropology in the study of disease and health among human populations. It grows out of the tradition in anthropology of holism and related attempts to develop biocultural approaches to anthropological issues. While these issues have been studied by physical and cultural anthropologists working independently of each other, the synthesis of the two areas can provide a clearer understanding of the role of disease and responses to it among human groups. This paper seeks to define a topical area, “biomedical anthropology,” which combines the theoretical and methodological aspects of physical anthropology and medical anthropology. This area, as so defined, provides a n approach to questions about health and disease from a broad anthropological perspective. The paper is based upon the tradition of holism in anthropology, seen as a discipline which, along with its other characteristics, is biocultural in perspective and integrative in its conceptual framework. The ideas expressed have resulted from the combined efforts of a physical anthropologist, with interests in human biology, nutrition, and growth and development, and a medical anthropologist, whose interests are in the areas of health behavior, medical care systems, health planning, and psychosomatic illness. It is our contention that a biomedical anthropological approach functions best when it emphasizes the biological basis of health and disease, while a t the same time actively incorporating a n understanding of the sociocultural nature of the sickness process. While our understanding of biomedical anthropology can encompass many studies that one might also include in the fields of medical ecology, medical anthropology, epidemiology, and human biology, there are a number of distinguishing factors that set biomedical anthropology apart. First, biomedical anthropology is based upon the application of anthropological theory to problems of health and disease. The theoretical orientation of anthropology, developed over more than a century of investigation, comparison, and generalization, includes both biological and cultural components. While useful research may focus exclusively upon either component, the deepest understanding of medical problems, and the greatest likelihood of successful interventions, come from the inclusion of both as well as their integration into a n analytic model that is biocultural. It is this characteristic that distinguishes biomedical anthropology from much of human biology, epidemiology, or medical ecology. Second, research is structured so as to focus upon a biological outcome. That is, biomedical anthropology is disease-centered and its investigations inquire into the impact of the disease (or condition) upon biological processes of individuals or the populations to which they belong. This characteristic distinguishes biomedical anthropology from medical anthropology and medical sociology. 0 1984 Alan R. Liss, Inc. 2 16 YEARBOOK OF PHYSICAL ANTHROPOLOGY [Vol. 27, 1984 Third, the domain of biomedical anthropological study incorporates both biological and cultural explanations of the health, illness, and disease processes. This is based upon the fact that many of these processes are understandable primarily within the context of culture and that biological causality may play only a minor role. This paper will first review the contributions of physical anthropology and medical anthropology to the development of biomedical anthropology. Examples of biomedical studies are then reviewed and evaluated. The paper closes with a brief concluding statement. PHYSICAL ANTHROPOLOGICAL APPROACHES TO THE STUDY OF DISEASE The study of disease from the perspective of physical anthropology has a long and significant tradition. In fact, the earliest studies predate considerably the formal emergence of physical anthropology as a science of human biological variation. For example, both Angel (1981)and Ubelaker (1982) have documented the beginnings of paleopathology in the first half of the 19th century. Examples from other areas of research in physical anthropology also indicate interests in the disease process developing hand-in-hand with those areas. Constitutional medicine, the study of morphological variability among individuals and groups as a factor in disease, has long reflected the input of anthropologists with their perspectives on methods and concepts (Damon, 1970), while the use of the methods and concepts of physical anthropologists in clinical settings has become increasingly more common (Robinow, 1982). In large part, the involvement of physical anthropology from its inception with studies of disease is due to the interest of many early researchers in the relationship between anatomical form and function, and particularly its corollary, the relationship between variations in form and abnormalities in function. A significant proportion of the original membership of the American Association of Physical Anthropologists, including its founder, Ales HrdliEka, was trained, not as natural scientists, but as physicians. The study of the disease process by physical anthropologists (as distinct from the study of individuals as carriers of the disease) received its greatest impetus with two developments within the biological sciences. The first was the rise of population biology, and particularly population genetics, as a conceptual approach to human variation and a s a body of methodology used in research and analysis. Among the theories of population biology was the concept that the “normal ” range of human biological variability was not only subject to, but was evidence of the operation of natural selection, and consequently of adaptive significance (Fisher, 1929; Coon et al., 1950; Ford, 1965). This led to the intensive search for relationships between genetic polymorphisms and disease by population geneticists during the 1950s and 1960s. Pollitzer (1981)and Weiss and Chakraborty (1982) have described this search and have discussed its contribution to our knowledge of genetic factors in disease. The second major development in the study of disease by physical anthropologists was the rise of ecology as a n approach to understanding the complexity of populationlenvironment interactions. As discussed by Sargent (1974, p. l), human ecology seeks to understand humans and their problems “by studying individuals and populations as biological entities profoundly modified by culture and by studying the effects of environment on man and those of man upon his environment.” A natural outgrowth of this development has been the rise of health ecology as a grouping of “basic and applied studies in medical ecology, epidemiology, medical anthropology, health and nutrition” (Little, 1982, p. 421). In fact, the integration of issues related to health and disease into nutritional anthropology has made this field of study almost a subset of biomedical anthropology (Roche and Falkner, 1974; Jerome et al., 1980).Whether we refer to the field of health ecology, medical ecology, or by some other term, it is clear that physical anthropologists and their colleagues in population biology have become deeply involved in the study of disease within human ecosystems. Johnston and Low] BIOMEDICAL ANTHROPOLOGY 2 17 The result has been, in the past several years, the development in physical anthropology of a n increased concern for the health-related outcomes of the interactions between humans and their ecosystems (see, for example, Watts et al., 1975; Foulks, 1972; Greene and Johnston, 1980; O’Rourke et al., 1983). In some instances, this work has documented outcomes which do not reflect specific morbid processes; rather they often document the likely deleterious effects of the environment (Cassidy, 1980; Schell, 1981; Bielicki and Welon, 1982). In others, particular diseases have been analyzed as cause and effect vectors within systems (for example, Drew et al., 1982). In summary, physical anthropology has been deeply involved in studies involving the effects of disease upon the human species. This involvement may be seen in a t least four different research areas of the discipline. First, it is evident in the work of those anthropologists who come from a medical tradition and who have explored the relationships between phenotypic and genotypic variation and disease. Second, it may also be seen in the research of those who, reflecting the rise of population biology, have examined the role of disease as a n agent in channelling the evolution and differentiation of human populations. Third, there is the development of a n ecological focus with its emphasis upon whole systems, including culture as a component, and with a n obvious involvement with the health outcomes of the population-environment interaction. Finally, there is the more recent rise of nutritional anthropology as a n area of research, one which provides a n organizational theme for ecological studies of health and disease. REVIEW OF MEDICAL ANTHROPOLOGY The major contribution of cultural anthropology to the study of health, illness, and disease is the application of the concept of culture to the health field and to the study of health culture (Clark, 1970). Ideas about health and disease are based on culturally determined beliefs and values. Explanatory models of disease causation are embedded in beliefs reflecting each culture’s theory of disease which answers the questions of diagnosis, etiology, nosology, and prognosis (Frake, 1961). These explanatory models can be identified as clinical models of patients and practitioners, which influence health behavior and the success of healing encounters (Kleinman, 1980). Functionally and symbolically, the products of health care also are a form of material culture that are translated from one cultural tradition to another with the diffusion of medical practices and ideologies. An excellent review of medical anthropology by Young (1982, p. 270) redefines the field as the study of the anthropology of sickness in which sickness is “a process for socializing disease and illness.” This socialization process is accomplished through the medical system, which translates the signs of illness into culturally meaningful forms and symbols of healing into symbols of power (Young, 1982, p. 271). Culture is defined by Goodenough (1981) as systems of standards for perceiving, believing, evaluating, and acting. Within a health-care setting, appropriate behavior may be learning the rules of error and morality among surgeons (Bosk, 1979)or how to get along with a n informal power structure of nurses and aides in a mental hospital (Goffman, 1961).The structure of medical institutions and the relationships created within these institutions produce a n environment where only some forms of illness behavior are tolerated or encouraged (Low, 1984). By defining the proper rules of behavior, the cultural content of the institutional structure is described. Medical systems are cultural systems (Kleinman, 1978) and, as such, determine the cognitive structure of health beliefs and practices and the institutional structure of medical care and treatment (Chrisman, 1977). Health and disease concepts exist only within the constructs of a particular culture and, therefore, cannot be studied without understanding these conceptual properties. Cultural anthropology provides various theoretical orientations to the study of the dimensions of health and disease. The most widely used orientations are briefly summarized in the remainder of this section. 2 18 YEARBOOK OF PHYSICAL ANTHROPOLOGY [Vol. 27, 1984 (1) Diffusion theory in anthropology argues that culture traits will be found among culturally related groups in a predictable pattern based on culture contact and trait diffusion. Murdock (1980) demonstrated that health behaviors and beliefs are organized by culture areas so that comparable behaviors are found in culturally related geographic areas. For instance, the culture area known as the circumMediterranean has been influenced by Galenic medicine, which was transferred by conquest and migration to the Middle East. This transfer of medical knowledge explains the similarity of the hot-cold systems of folk medical practice found in Hispanic, Italian, Greek, and Iranian cultural settings (Foster and Anderson, 1978; Good, 1977; Harwood, 1981). (2) Symbolic theory in anthropology analyzes rituals and symbols through the systematic decoding of meaning and the examination of the relationship of the symbol to the cultural system. The symbolic aspects of health behavior are well documented in Western medical practice (Fox, 1979) and within indigenous medical traditions (Turner, 1967). These symbolic meanings may influence treatment success particularly in pluralistic medical contexts, such as the demonstration projects in New York City and Puerto Rico which incorporate espiritistas as part of the mental health therapy (Garrison, 1977; Koss, unpublished manuscript). The symbolic content of healing is part of curing and caring efficacy such that changing the context influences the outcome of the therapy and affects the healer-patient relationship. Cultural symbols also play a role in the interpretation of symptoms. Cultural groups select symptoms and their expressions of illness as part of their communication of sickness within a system of meaning. For instance, among the Gnau of New Guinea, a n ill person rubs dirt on his or her body, and separates himherself from the social group to signify a state of illness. The person is expected to remain passive and to wait for others in the kin group to provide therapy and to decide what is wrong (Lewis, 1975).In the United States, this same behavior may or may not signal illness and would be interpreted as inappropriate sick role behavior. Symptoms are also culturally specific, and cultural groups may develop what have been labelled “culture bound syndromes,” such as arctic hysteria (Foulks, 19721, Zutuh (Kenny, 1983; Carr, 19831, and lzoro (Jilek, 1983). Symptoms such as the “sick” livers of France, heart sickness in Iran (Good, 19771, and the prevalence of nerves in Costa Rica (Low, 1981) are more common examples of culturally appropriate expressions of distress encoded in symptoms that have symbolic meanings in their particular cultural setting. (3) Functionalism in anthropology provides a view of culture as a homeostatic, readjusting system. From this perspective, health behavior reinforces dominant cultural patterns and themes through societal sanction, social validation, and removal of social responsibility. Behaviors which otherwise would appear socially disruptive are redefined as acceptable and manageable through the designation of appropriate sick role behavior or the absolution of guilt by the healer or priest. Medicine and religion perform the same societal function and can be analyzed as a continuous societal process (Fox, 1979). (4) The cognitive perspective in cultural anthropology has contributed to the explanatory models of illness and disease (Kleinman, 1980),to ethnosemantic studies of illness categories and behaviors (Fabrega, 1977; Frake, 1961), and to health decision-making models for medical choices (Young, 1980). Cognitive explanations of culture are applied to diagnosis, whether from the patient’s perspective of selfdiagnosis which begins the health-seeking process, or from the physician’s perspective of variation within biomedical diagnosis (Gaines, 1979). Cognitive categories are useful for predicting health behavior and explaining systems of lay referral and self-care. (5) The relation of illness to social structure has a theoretical tradition in anthropology and sociology, and has been applied in studies of medical institutions and the helping professions (Krause, 1977, Loudon, 1976).Anthropological studies of African healing and ritual document the micropolitical aspects of the healer-patient interaction and the role that illness plays in realigning social relations. Social structural Johnston and Low] BIOMEDICAL ANTHROPOLOGY 2 19 analyses outline the complex set of social relationships that are embedded in the sickness process and that influence health outcomes. These five theoretical perspectives provide a general basis for a cultural analysis of health behavior, beliefs, and values. The perspectives presented are common to cultural anthropology and applicable to any of the various subdisciplinary units. Medical anthropology, from its own historical and theoretical evolution, has developed a number of concepts which provide additional insights. Since its inception, medical anthropology has studied health care as part of a n ethnographic context. Health-care systems are cultural systems (Kleinman, 1978); the rules of analysis are the same as those employed in more general ethnography. Ethnography, the cultural description, provides a basis for health culture analysis. The concept of health culture in medical anthropology is employed to describe the ethnographic context of health behavior. Weidman (1979) defines health culture as all phenomena related to the maintenance of well-being and problems of sickness with which people cope in traditional ways within their own social networks. This definition includes both the cognitive and social systems, belief and practice, in the health culture domain. Health culture descriptions provide a framework of rules and meanings for culturally appropriate health behavior. Many models of health behavior, however, do not focus solely on the cultural definitions of health; instead they emphasize the sick role and social aspects of illness behavior and medical care (Parsons, 1958; Kasl and Cobb, 1966; Foster, 1978; Segall, 1976; Idler, 1979). Variations in health behavior are explained by differences in educational levels (Croog, 1961), medical orientation (Suchman, 1964; Farge, 1978), religion (Mechanic, 19631, self-concept (Kassebaum and Baumann, 1965), sexual status (Nathanson, 1977; Verbrugge, 1978), social class (Hollingshead and Redlich, 1958), and referral network (Zola, 1973). The studies are predominantly based on research within the United States. Cultural concerns are included in these models as differences in illness behavior observed between ethnic groups (Zborowski, 1952; Mechanic, 1966; Wolff and Langley, 1968; Zola, 1966) and in relation to cultural role expectations (Townsend and Carbone, 1980). The variables relate health behavior to social group characteristics and psychosocial explanatory factors. Medical anthropological research in the United States has also explored the importance of family context in health behavior and the treatment of illness (Henry, 1965; Reynolds and Farberow, 1981). Studies have shown that the role of the family in illness etiology may provide insights into the inclusion of family members in treatment. Family interaction is identified further as a source of the psychosomatic disease process and illness control (Goldberg, 1958; Titchener et al., 1960; Bursten, 1964; Jackson and Yalom, 1966). The family as a mediator of health care and as the major culture bearing unit which influences individual health behavior has been described for Mexican-American families as they enter the United States healthcare system (Clark, 1970; Rubel, 1966). Medical anthropological contributions to health behavior models have expanded sociocultural and psychosocial variables, and have introduced the concepts of dual use and the hierarchy of resort in curative practices. Studies of health behavior outside of the United States have consistently reported the use of many health-care strategies in any one illness episode. Dual use (Press, 1969; Garrison, 19771, the concurrent use of a physician and a curer for treatment of a n illness, and hierarchy of resort, the order in which a patient chooses such treatment (Romanucci Schwartz, 1969; Colson, 1971; Nichter, 1978), are constructs generated by the medical anthropologist to account for cross-cultural aspects of health behavior. The analysis of cultural patterns of health-care utilization further stimulated research on why indigenous practices heal successfully (Kleinman and Sung, 1979), and how indigenous healing practices benefit the patient (Heggenhougen, 1980; Finkler, 1980; Ness, 1980). These perspectives are integrated in studies of changing medical situations in which alternative curing strategies are examined by medical resource availability (Woods, 1977) and models of natural decision making (Debacher, 1979; Young, 1980). 220 YEARBOOK OF PHYSICAL ANTHROPOLOGY [Vol. 27, 1984 Studies of doctor-patient interaction and patient satisfaction also have added to a n understanding of health behavior. Research indicates that the fulfillment of social needs (Kurella, 1979),the physician assignment procedure (Gray, 1980),the personal characteristics of the physician (Locker and Dunt, 1978; Woolley et al., 19781, and the degree to which physician performance corresponds to patient expectations (Larsen and Rootman, 1976) influence the patient’s reported satisfaction with medical care. The health-seeking process as described by Chrisman (1977) integrates the social and cultural factors that influence health behavior. In this model, cultural factors influence patient symptom definition at the beginning of the illness episode, while social factors predominate during referral and treatment action. Finally, the degree of sociocultural integration determines patient adherence to the prescribed regimen. Chrisman (1977, p. 371) concludes that “The quality of doctor-patient transactions and the degree of adherence is enhanced by specific practitioner attention to explanatory models, role constraints, and the views and influence of lay consultants.” Chrisman’s model adds the new dimension of explaining patient behavior in terms of the entire illness episode, and in predicting adherence based on the influence of the successful integration of social and cultural factors. Field applications of medical anthropological concepts and methods have explored two kinds of resistance in terms of health care improvement: (1)the resistance of the community to receiving new health services, and (2) the resistance of the medical bureaucracies to changing their modes and explanations of health-care delivery. These two kinds of resistance influence the acceptability of biomedicine and are discussed with examples from medical anthropological health projects. Communities receiving new health services often respond by rejecting the medical clinic because of a conflict between their folk explanatory models of health and proper bodily functioning, and the professional model being imposed by the incoming nurses and physicians. This conflict is referred to as the “adversary model” (Foster and Anderson, 1978),which implies that the folk and professional systems are really in a n adversarial position to one another. Often, the incorrect assumption is made that the community has no health care if there are no modern medical services, and it follows that people, therefore, are thought not to have strong ideas about their bodies and health care. Medical anthropological research has demonstrated that people cannot be thought of as “empty vessels” waiting for the health-care gap to be filled by medical services. A community’s ideas about health may in fact be the strongest and most tenacious part of their cultural repertoire, and may be reinforced by religious and moral beliefs. Another area of community resistance relates to the community’s diagnosis of illness and whether that diagnostic category is considered appropriate for medical treatment. There are a number of folk illnesses such as evil eye, empacho, fallen fontanelle, and susto, found among Mexican-American and Hispanic populations, that the community defines as their own “cultural” illnesses. These illnesses are taken to folk practitioners for treatment rather than to biomedical physicians, since the physicians are thought not to understand or treat adequately these indigenous diseases. The notion of culture-bound syndromes may also be applied to mainstream American culture. Ritenbaugh (1982) and Cassidy (1982) have argued that obesity and protein energy malnutrition display the characteristics of culture-bound syndromes. However, many of these illnesses affect children and are related to diarrheal problems which dehydrate and often kill the infant or young child. This conflict of cognitive categories must be dealt with in order to treat these children successfully. Other community resistance to medical treatment focuses on the role of the hospital a s a place to die and where proper attention will not be paid to disposal of body parts or sacraments. Foster (1969; see also Foster and Anderson, 1978) has suggested that the medical service community also has resistances which influence the acceptance of health care. These resistances are even harder to understand, but are just as persistent and Johnston and Low] BZOMEDICA L ANTHROPOLOGY 221 fit within the cultural framework of the biomedical profession. Foster points out that there are some erroneous health planning assumptions, beginning with the assumptions that the western biomedical model is the best, and that the separation of preventive and curative medicine is necessary for technical competence. There are differences in personal priorities of daily activities and personal needs that make changes in scheduling that would accommodate community members difficult for biomedical practitioners to accept. Medical personnel often do not consider the decision-making role of the patient and, therefore, overlook the important role of the family in the decision-making and treatment procedures. Often in treatment, side effects of drugs that are not considered a problem among the population are important in other contexts. For example, in Latin America the side effects of birth control pills, i.e., bodily changes and differences in menstrual flow, are perceived as important health-related changes and dangerous to one’s femininity and well-being. These same side effects are tolerated by North American women with minimal complaint. The differences in perceptions affect both the quality of biomedical research and the effectiveness of biomedical intervention. In choosing the biomedical case studies to be presented, only three of these cultural perspectives are subsequently illustrated: the functional (evident in Livingstone’s analysis, 19581, social structuralism (in Greene’s studies, 1973, 1974, 1977, 1980), and symbolism as well as social structuralism (in Lindenbaum, 1979). The other perspectives are implicit in these works, but are not part of the research frameworks which were employed. EXAMPLES OF STUDIES IN BIOMEDICAL ANTHROPOLOGY While the numbers are certainly not overwhelming, there are examples of biomedical anthropological studies which conform to the criteria discussed in this paper. Some studies have been society-specific,focusing upon the intense examination of a particular community in well-defined and delimited environments, and observed either synchronically or diachronically. Others are broad in scope, covering regions, continents, andor long periods of time, gaining in comprehensiveness what may be lost in context. All such studies, however, clearly are biological in outcome, in that they examine some disease or condition, and all studies analyze cultural data as essential steps in solving ecological relationships or testing hypotheses. Sociocultural data are not invoked casually as “possible causes,” but provide crucial inputs needed to solve specific problems. Studies which may be called biomedical anthropology may be characterized as biocultural in the best sense of the term. We have chosen three studies as the best examples of biomedical anthropology as we have defined it in this paper. Each study reflects the use of both cultural and physical anthropological theory, but each case was selected for the degree of clarity and integration of biological and cultural factors. These three studies are: (1)Greene’s description of the ecological relationships among goiter, physical and mental development, social structure, and culture in highland Ecuador (Greene, 1973,1974,1977, 1980); (2) the study of kuru as a bioculturalhiomedical problem related to ritual behavior (Lindenbaum, 1979; Gajdusek, 1974,1977; Gajdusek and Gibbs, 1975); and (3)Livingstone’s analysis of the distribution and adaptive function of the sickle cell allele in West African populations (Livingstone, 1958). Biomedical anthropological aspects of goiter in Ecuador In a series of papers published between 1973 and 1980, Greene has described his intensive research on endemic goiter in the Andean region of Ecuador. He has characterized the central issue underlying his work as “the extent to which long or short term environmental factors . . . can affect the phenotypic expression of the genetic potential in specific biological systems” (Greene, 1973, p. 119).Furthermore, his work examined the consequences of such a situation, including sociocultural adaptations. Greene’s work was conducted in two Ecuadorian communities located between 2,700 and 3,100 m above mean sea level with a prevalence of goiter, at the 222 YEARBOOK OF PHYSICAL ANTHROPOLOGY [Vol. 27, 1984 time of the study, of 52.8% and 69.7% (Greene, 1974). A broad range of data was obtained on community members with and without goiter, including measures of morphology, growth, neurological maturation, diet, and taste sensitivity to PTC (phenylthiocardamide). In addition, Greene collected ethnographic and environmental data, allowing him to analyze his observations within the context of a model employing interactions among three components of the ecosystem: (1)biological, (2) sociocultural, and (3) environmental (Greene, 1977). A number of conclusions have emerged from Greene’s work. Neurological deficits, which occurred a t higher than expected levels, ranged from the frankly retarded cretins through a continuum of expression to the normal. Sensitivity to PTC was correlated with visual-motor maturation among individuals who had not received iodine supplementation. This was viewed by Greene as a n oral mechanism “for avoidance of bitter tasting naturally occurring goitrogens” (Greene, 1974, p. 149). Cultural factors were seen as interwoven throughout the network of interrelations between biologic factors and the environment. Protein energy malnutrition, detected both from measurements of physical growth and analyses of diets, was exacerbated in some children who were weaned a t a relatively early age to a low protein diet. Of particular interest from biocultural and methodological points of view was that a quantitative measure of socioeconomic status developed by Greene was not nearly so highly correlated with neurological maturation as was a six-stage subjective evaluation given by his native informants. Greene noted that the “subjective” evaluation was not only diachronic, and hence more stable over time; it also incorporated “educational and behavioral judgment,” which were probably important (Greene, 1980, p. 243.) Greene found a number of other cultural correlates of endemic goiter and its neurobiological sequelae. Historically, highland Ecuadorian social systems are highly stratified and accommodations to the large numbers of behaviorally limited individuals were noted. The definition of “normal” was lowered considerably, and any individual with more than minimal language and hearing capacity was judged to be normal. The fatalism of the Roman Catholic religion of the area, with its acceptance of deaf-mutism as “God’s will,” may be interpreted as providing a n ideational adaptation to this condition as well as to the extreme poverty and low social position of the indigenas and mestizos (Greene, 1977). Furthermore, the familial nature of the society enhanced the integration of the behaviorally limited into their family and the community. Finally, Greene writes that the greatest societal impact of a large number of neurologically limited individuals is in creating a large pool of cheap labor which benefited the wealthy landowners. The resulting relationships, largely exploitative, involved “extreme displays of affection” (Greene, 1977, p. 89) by the landowner for his workers, fostering a system of mutual interdependence. The biobehavioral consequences of goiter resulted in a unique social structural configuration in which stratification was intimately linked to the distribution of the disease in the population. Greene’s study has demonstrated clearly that no one aspect of this system-goiter, malnutrition, neurological function, social structure, or cultural values-can be understood fully without consideration of the other aspects. The biomedical outcomes, neurological deficits and malnutrition, are maintained by an environment in which goiter is endemic and by a social system which fosters social and ethnic stratification and inbreeding, yet which depends upon the existence of neurologically limited individuals for its maintenance. Both biological and cultural adaptations are described, and these adaptations result in the biological and sociocultural stability of this ecosystem. Kuru, ritual behavior, neurological disease, and biomedical anthropology The analysis of the ecology of kuru presents us with another example of biomedical anthropology, in which cultural and biological components have been integrated into a holistic framework, focusing upon the disease as the outcome. In addition, Johnston and Low] BIOMEDICAL ANTHROPOLOGY 223 this work has provided medicine with the discovery of a new class of viruses. By so doing, it has extended beyond traditional anthropological concerns and demonstrated that the study of the diseases of the world’s remote societies could contribute significantly to health care in the modern world. It is of great interest to biomedical anthropologists that the Nobel Prize in medicine, awarded jointly to D.C. Gajdusek and B.S. Blumberg in 1978, for their work on neurological viruses and the transmission of hepatitis, respectively, was a n overt recognition of the role of biomedical anthropological research in providing health care. The story of kuru was not unravelled by a single investigator, nor a single research project. However, the work of two investigators stands out. The first is D.C. Gajdusek, who began his work in the mid-19507s,engaging in a comprehensive set of clinical, epidemiological, and experimental studies (e.g., Gajdusek, 1974, 1977; Gajdusek and Gibbs, 1975). The cultural context was provided and elaborated by the ethnographic work of Lindenbaum (1979) in Wanitabe, a settlement of the Fore people of the Eastern Highlands of Papua New Guinea. Kuru (the term is taken from the Fore language and means “trembling” or “fear”) is a progressive, fatal neurological disease characterized by cerebellar ataxia and tremor, progressing in about a year from initial symptom to death. It is confined to about 160 villages in Papua New Guinea with a total population of some 35,000 people (Gajdusek, 1977).Its highest incidence has been among the South Fore where, between 1957 and 1968, 1,100 kuru deaths occurred in a population of some 8,000 persons (Lindenbaum, 1979). While the place of origin of kuru is controversial, its spread among the Fore villages has been well documented from the earliest case recorded in Kasokana in the early 1920s, to a society-wide distribution by 1942. Western scientists began to study the disease in 1955 and a series of etiologies was suggested, both psychosomatic and genetic. However, Gajdusek was able to establish that kuru is caused by a virus characterized by a n extremely long period of incubation, up to 20 years. The kuru virus has other unconventional properties. It remains stable for many years, even after freeze drying, and is not inactivated totally after being subjected to a temperature of 85°C for 30 minutes. Antibodies to it have not been detected nor is there other evidence of a n immunological response. It has been transmitted experimentally to apes and monkeys (but only to primates) (Gajdusek and Gibbs, 1975). As a biocultural phenomenon, kuru is of greatest interest because of its transmission via cannibalism. The Fore adopted cannibalism, perhaps in about 1910, a decade or so before the appearance of kuru. Lindenbaum has concluded that the eating of human flesh was brought about by the progressive removal of the forests and its animal life as a consequence of increased population pressure and the spread of the sweet potato as a dietary staple. The loss of this source of protein was compensated by the keeping of domestic pig herds and the rise of cannibalism. The cannibalism involved the ingestion of flesh, including the brain (in fact, all but the gall bladder). However, the most likely routes by which the virus was introduced into the host were not by way of the gastrointestinal tract, but by means of the skin, through cuts or sores, or from unwashed hands being rubbed on the nose and in the eyes (Gajdusek, 1977). This is of particular significance since the preparation of the corpse was a task carried out by women and children (Lindenbaum, 1979). The mortality patterns associated with kuru parallel the cultural practices described above. Death rates have been especially high among adult women. At its peak incidence, the mortality from kuru among females was more than four times that of males. It has also been common among children, who may become contaminated not only through their own activities but also from contact with their mothers. Because of the sex differential in mortality, some Fore villages have male-to-female ratios of more than 3:1, and for all of the South Fore the ratio is 2:l. As was the case with Greene’s study, Lindenbaum showed that the disease made a major impact upon the sociocultural system of the society. Among the Fore, cannibalism played a significant part in changing women’s roles as well as in generating new ritual behavior in response to the increase of illness and disease 224 YEARBOOK OF PHYSICAL ANTHROPOLOGY [Vol. 27, 1984 among women. Concerns with ancestral punishment and the symbolic meaning of kuru came to dominate the villagers’ perceptions of the problem (Lindenbaum, 1979). With the imposition of Western law the incidence of both cannibalism and kuru have decreased dramatically and the disease is now rare in children under 12 years of age (Gajdusek, 1974).The greatest decline has been among women, who would be affected most by the cessation of cannibalism as a cultural practice. The description of the bioculturallenvironmental ecosystem associated with kuru is an excellent example of the biomedical anthropological approach. But, the utility of this approach is seen further in the importance of these studies for modern medicine and microbiology. The elucidation of the epidemiology of kuru has shed much light on a series of related slow viral disorders including Creutzfeld-Jacob disease, scrapie (in sheep), and transmissible mink encephalopathy (in mink). In his 1977 paper, Gajdusek has noted that we have obtained new insights into other presenile dementias, into Alzheimer’s disease and the senile dementias, and perhaps into other degenerative diseases such as multiple sclerosis, amyotrophic lateral sclerosis, and Parkinsonism. That these conditions show certain specific associations with particular populations or environments suggests that “some common etiological factor may underlie the occurrence of all these very different syndromes” (Gajdusek, 1977, p. 959). Sickle cell anemia and genetic adaptation Livingstone’s (1958) analysis of the distribution of sickle cell hemoglobin in West Africa has become a classic in human population genetics and the study of human adaptability. It is also a landmark in the development of biomedical anthropology. Livingstone’s work is well known and widely cited in virtually every textbook in physical anthropology, so it need not be detailed here. However, its importance for biomedical anthropology should be noted. By analyzing the patterns of gene frequency distribution within the contexts of cultural ecology and archeology, Livingstone demonstrated that a deleterious allele, responsible for sicklemia, was also a n important factor in adaptation to falciparum malaria. Following up on Allison (1955), Livingstone showed that the concept of the balanced polymorphism could be seen in human gene pools, pointing the way to subsequent analyses of the ecological genetics of disease. In his work, Livingstone’s perspective was a dual ecological and functional one. It was ecological in that it involved a detailed analysis of the west African swidden agricultural ecosystem, emphasizing the close interactions among subsistence strategy, the increased incidence of the anopheles mosquito as a vector of malaria, and the evolutionary response of the gene pools of the populations. In contrast to Greene and Lindenbaum, who documented the effects of a disease upon culture and social structure, Livingstone documented the effects of cultural practices (swidden agriculture) upon disease incidence and ultimately upon the structure of the gene pool. In all three cases, fine-grained ecological analyses were utilized to make the biocultural link. Livingstone’s approach was also a functional one in that he showed how evolutionary mechanisms worked to restore a n equilibrium condition. The increase in malaria prevalence was accommodated by an increase in the frequency of the sickle cell allele, which may be viewed as restoring or maintaining the groups involved as functional populations and societies. Just as important, Livingstone produced one of the first clear and detailed examples of the close association between culture, biology, and the disease process. His model indicated that sicklemia and the distribution of the sickle cell allele could not be understood without a n understanding of the cultural processes working historically in human ecosystems. This work provided the model which has been followed by many other investigators in studying the relationships between genetic variation, disease, and cultural practices (e.g., Simoons, 1978; Strober, 1983). CONCLUDING COMMENTS Both physical and medical anthropology have contributed much to our understanding of the concepts of health and disease, and to the systems of health care by which Johnston and Low] BIOMEDICAL ANTHROPOLOGY 225 a people seek to maintain their sense of physical well-being. Because of their biological traditions, physical anthropologists have focused their research efforts upon the ecological and evolutionary outcomes of disease pathology, in individuals and populations, utilizing western models of science and disease. Medical anthropologists, reflecting their primary identification with cultural anthropology, have been directed by cross-cultural concerns, by the notion of cultural relativism, and by a n emphasis upon the cultural background and its relationship to sociocultural phenomena. Their research, as a result, has focused upon the systems of meaning and behavior underlying the concepts of health and disease. While each of these areas of study may be seen as complete within themselves, it is our contention that the greatest contributions to knowledge, and the greatest service to the holistic traditions of anthropology, have come from the integration of the two. We have chosen to call this integration biomedical anthropology. A biomedical anthropological approach requires significant and sophisticated contributions from both the biological and the cultural. By bringing both to bear upon a specific health-related issue, the likelihood of attaining a solution which leaves but a few loose ends is enhanced, to say nothing of the contribution to those fields, such as public health, which must intervene to bring about some preplanned end. As the various threads which constitute anthropology have gone on their own, they have steadily become more isolated from each other through increasing focus upon specific problems and through the increasing development of specialized methodologies. 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