[This article is based on a talk forPeace Corps Pre-Service Training, Ta'izz, Yemen, July 27,1993.]
Medical anthropology looks at culturalconceptions of the body, health and illness. It also focuses onhealth behavior as a way to learn about social values and socialrelations. Medical anthropology research has much to contribute toprojects being designed to improve health service delivery and healtheducation. Health projects often proceed upon the assumption that"if we teach people `correct' health beliefs and behaviors, they willadapt their behaviors and become healthier." Numerous studies (e.g.,Jordan 1989; Mull and Mull 1988; Nichter 1985) have found that newknowledge does not necessarily translate into behavior change. Thedesire to empower people with knowledge is laudable. However,failure to recognize local knowledge and relations of power andauthority leads to a lack of appreciation of contingencies whichaffect health behavior.
In the summer of 1993, with the assistanceof a fellowship from the American Institute for Yemeni Studies, Iconducted medical anthropology research at the outpatient clinics ofAl-Thawra Hospital in Sanaa. The high turnover of patients at theclinics, with doctors having only two or three minutes per patient,provided an excellent opportunity to survey the implications ofhealth conditions in Yemen. In this paper, I will discuss the socialand cultural context of health care seeking as a means ofillustrating: 1) the importance of health beliefs and practices; 2)variability among patients; and 3) social relations of health careseeking. Specifically, I will focus on the following three arenas of"knowledge": a) ethnophysiology, b) etiologies, and c) treatments andhealers; as well as the following three arenas concerning"variability among patients": a) the household production of health,b) the therapy management group, and c) moral identity. My intentionis not to provide an exhaustive account of illnesses and treatments,nor a detailed description of Yemeni society. Rather, I offer aseries of examples to illustrate the social context of health andillness, of which biomedicine forms a part. It is my hope that theconcepts presented here will be useful as "tools" to othersattempting to learn more about Yemeni society, especially thoseplanning health and development intervention.
Ethnophysiology
Ethnophysiology considers people'sunderstandings of how their bodies function. These understandingsinfluence health practices, symptom evaluation, and health-careseeking. That people's perceptions of the workings of their bodiesmay differ from the physiology of medicine can be seen in thefollowing exchange. After a doctor in the Orthopedic Clinic of thehospital listened to an older woman describe her upper back pain, heturned to me to say, "Sometimes we can't understand their complaint. She's saying that while eating, she gets a pain in her back. I don'tbelieve her. She feels as if her back is open like a window."
Local perceptions of how the body worksunderlie women's concern that an IUD will cause headaches and areevident when they speak of the placenta coming out of a woman'smouth. Such ideas are associated with the perception that the areabetween the abdominal region and the head is hollow, so that anythinginserted in the vagina can travel to the head. Notions ofethnophysiology also underlie women's ideas about menstrual blood andconception. In her research in the Hujariya, Cynthia Myntti(1985:168) describes the belief among women she studied thatmenstrual blood and vaginal fluids should be eliminated regularlyfrom the body lest they cause physical disorders. This popularizedversion of the Galenic-Islamic tradition also exists among Iranianwomen, who are encouraged to have babies early in marriage becauseuntil women have given birth, their body is in a less healthy statesince it is polluted with excess menstrual blood (Good 1980). Womenbelieve that the contraceptive pill causes polluted blood to remainin the body and so are reluctant to use it (See also Morsy 1980 forEgypt).
In addition, women's willingness to use thepill is affected by their understandings of conception. Common tothe Middle East is a "monogenetic" notion of procreation (Delaney1991). Here, the man provides the seed, while the woman provides"the vessel in which the seed grows" (Good 1980:149).1 Thus, saysGood, a woman is greatly concerned about the condition and health ofher uterus or "vessel." Women are again encouraged to have babiesearly in marriage, as the condition of the uterus in a younger womanis believed to be better. Because of the popular focus on the uterusas the female's contribution to reproduction, women are concernedabout the effects of the contraceptive pill on the uterus. They fearthat its use may result in the drying of the uterus and a loss offertility (Good 1980:152).
The above examples illustrate the importanceof research on ethnophysiology to an understanding of women'sreproductive health.
Research on explanations of illnesscausality sheds light on health care behavior. In Yemen, in additionto biomedical explanations, illnesses are attributed to the sun, jinn[spirits], a bad scare [fij'a, Swagman 1989],or the evil eye, among others. Perceived causes of illness affectpeople's attempts to explain bodily occurrences in clinics. Forinstance, a girl in the Dermatology Clinic had a white mark on theback of her neck. The doctor told me that her mother was concernedthat this ailment was very serious and would spread; she saw it as apunishment from God. Another instance is of a young woman in theNeurology Clinic who complained of headaches. She said that theheadaches began after someone had told her about a car accidentoutside, which had given her a fright (fij'a).
Examinations of etiologies entail anexploration of folk epidemiology, factors which lead to vulnerabilityand susceptibility, as well as what can be done to avoid the risks. For example, direct sunlight is avoided as a cause of illness,especially for children ( Myntti 1985). Accordingly, a man crossingthe street in front of the hospital shielded his baby and called outto the crowd, "Ash-shams, ash-shams (the sun, the sun)" toclear a path to remove the baby from the sun.
A closer examination of one cause ofillness, the evil eye, will highlight how local notions of etiologiesmay influence health projects. The evil eye (hasad oral-'ayn) results from an envious or covetous gaze. Due to fearof the evil eye, pregnancies may be kept secret, as pregnancy is avulnerable transitory state. Infertile women are often seen as asource of the evil eye. In addition, mothers may be reluctant toweigh babies or chart their growth as this might provoke envy of adesired condition. Toddlers may be left dirty so as not to drawattention to their beauty, which would make them susceptible to theevil eye.
The evil eye can provide a satisfyingexplanation for otherwise inexplicable events, such as in thefollowing illustration. A woman told me about her sister who hadlong hair and was beautiful. On the day of her own wedding, thesister danced, swinging her loose hair in the Hodeida style. Eversince that day, for the past twenty years, she has suffered from aheadache and her hair has been falling out. The woman said that hersister's condition was the result of hasad from one woman at thewedding. She does not know who it was, but said that the only cureis to wait for the inflicting woman to die.
The evil eye can also affirm that one hasdesirable skills or characteristics and therefore provides comfortwhen facing mishaps. Illustrations of this include a young man inthe Dermatology Clinic who complained of blotches around his eyes forthe past four months. He attributed his condition to hasad. Somegirls, he explained, had said how handsome he was, and then theblotches appeared. Another instance is of a woman in theOphthalmology Clinic who told how she had given herself and anotherwoman an injection as she lives faraway where there are no doctors. She said that the other women present were surprised by her abilityto give an injection, which caused the medicine to splash in her eye.
Multiple explanations for illnesses havesurvival value in that they are reassuring and help people cope withmisfortune. Health projects planning to displace local explanationsfor illness by strictly biomedical interpretations need to considerthe social relations of illness attribution. Comfort may be replacedby blame, as the following example suggests. One woman had accused aneighbor man of being the cause of her baby's illness. She told methat the man was jealous of her husband for having so many children(eighteen to the other man's seven). While a biomedical explanationfor the baby's illness might lay blame on her for bad mothering,perceptions of blame elsewhere helped her cope. Health projectsshould offer people ways to improve their health while respectingtheir dignity. Projects should be cautious not to blame the verypeople they are trying to assist.
Signs that patients have used "traditional"(i.e. non-biomedical) treatments and healers are evident inoutpatient clinics. For example, some patients have strings orscarves tied around their abdomen or ankles to alleviate pain, othershave scars or scabs from cauterizing, still others mention treatmentsof cupping or blood-letting. In the Orthopedic Clinic, severalpatients I interviewed had been first to a tabib 'arabi("Arab doctor," traditional bone setter in this case) to havetheir bones set. Unfortunately, in many of these orthopedic cases,the treatment proved iatrogenic. For example, when the gauze waswrapped too tightly, it cut off blood circulation which lead to agangrenous arm that then needed amputating.
Self-medication from pharmacies is popularin Yemen (Myntti 1988). Especially popular are vitamin tonics(muqawiy¡t, which are related to "strength"). People may alsovisit private clinics specializing in first-aid, injections, IVs, andcircumcision. Herbal remedies are also used, such as by the man whotold me that he changed to an herbal remedy after prescribedmedication had upset his stomach. In addition, receiving adiagnostic test or x-ray is sometimes viewed as a treatment initself. Diagnostic analyses have become quite fashionable, as thefollowing example describes. A doctor pointed out the case of an oldwoman from a rural area who has high blood pressure. One of her twoelderly male companions asked for her to have a kambuter (from"computer") test (a CT scan). Although the test was unrelated to hercondition, the technology (al jih¡z al jadid) was new anddesired, familiar to people from rural areas as well.
It is important to realize that people maybe trying a variety of treatments and healers in their search for acure. Thus, they are not necessarily choosing one medical "system"over another; they are looking from something that works. A casestudy will help illustrate this search for a cure.
A one-and-a-half-year-old boy was in thePediatrics Ward for repeated convulsions similar to epilepsy. Hismother, who estimated her own age to be nineteen, was staying in thehospital with him. He was her only child. The boy was four monthsold, his mother said, when the first convulsion occurred. She andher husband were afraid, of course. They tore off the baby's clothesand put water on his face. Afterwards, they took him to aneurologist at the hospital who said that nothing could be done forhim as he was young and the medicine would be too strong for him. The doctor told them to take the baby back home and wait until he'sbigger.
A second fit occurred five days later. Withthe advice of a neighbor, they went to a shaikh, a religious healer. The shaikh read from the Quran and cut off the neck of a chicken. Herubbed the blood on the baby until it dried. The shaikh told themother to bring olive oil to him. He read Quranic verses over theoil. He told her that when a fit occurs, she should rub the oil onthe baby.
Another fit occurred. The mother rubbed theoil on the baby, but there was no effect. She went back to theshaikh. He told her to remove any pictures off the walls of theirhouse. Fits came several times again. She again returned to theshaikh. He told her to take the baby to a doctor orhospital.
They returned to the neurologist when thebaby was eight months old. He suggested tests and medicine. He saidhe could not diagnose the condition exactly but to use the medicine. She used it for a month and a half while the fits continued. Thedoctor then changed medicines several times without anybenefit.
Finally, the boy was admitted to thehospital for investigation and treatment. Theone-and-a-half-year-old boy and his mother had been in the hospitalfor three weeks. The day I met them, a doctor had said they mighthave to go out of the country for treatment as it was not availablein Yemen. The boy was still having fits &emdash; four to twelve aday.
This case of convulsions containsinteresting parallels between the shaikh and the doctor. Neitherknows what is causing the fits nor exactly how to cure the condition. Both try a variety of treatments, not only to stop the convulsionsbut also possibly to tell them something about the unclear causes. In both situations, the health practitioner confronts an unknown,which highlights the rather mysterious process of illness andhealing.
The search for a cure is a process ofalternating doubt of, hope for, and commitment to remedies andhealers. Medical practitioners should recognize that patientsvisiting them are at different points in this search for a cure. Patients may be involved in a multiplicity of treatments,sequentially or concurrently. The visit to the doctor, therefore,may be one attempt of several, such as with the mother who broughther daughter to the Pediatrics Clinic. She carried medication withher, which she had purchased from a pharmacy the night before. Sincethe medicine had proven ineffective (during the far fewer than 24hours that had passed since trying the medicine), she was in theclinic the next morning looking for another remedy. What we do notknow and what needs to be researched further are people'sexpectations for treatments and the length of time that they arewilling to suspend their doubt or sustain their hope as they await aresult.
In the preceding sections on"ethnophysiology" (people's understandings of how the bodyfunctions), "etiologies" (people's explanations as to the causes ofillnesses), and "treatments and healers" (what people do to relievediscomfort), I have discussed local knowledge, which may beunfamiliar to those trained predominantly in clinical medicine. Ihave done so in order to encourage further exploration of healthbeliefs and practices.
In the next sections, I will discussvariability among patients, affected by household dynamics. I do soin order to emphasize that a person is not an isolated unit. Thisreminder is necessary since health projects often target individualmembers of a household, such as mothers or children, while seeming toforget that individuals rarely act alone regarding their healthbehavior. A person's access to health care, for instance, is oftendependent on his or her status and position within a household. Forthis discussion, I will introduce the concept "household productionof health."
The concept of "the household production ofhealth" (Berman, et al. 1989) recognizes that a person's access toand use of various forms of treatment are connected to his or hersocial power in relation to other household members. Here, a"household" is examined rather than a "family," as a household may beeasier to define. A household in Yemen may include, for example,other relatives living in the house, a divorced relative (e.g., thehusband's sister), children from a previous marriage, co-wives, or anabsent father. A study of "the nuclear family" or "the extendedfamily," or even "the family," would not explicitly account for thesemembers. Studies of the "household production of health" examine howhousehold members cooperate and compete for resources in order torestore, maintain, and promote health. Such analyses, therefore,highlight the variability in autonomy, status, power, and access toresources existing among household members. Household dynamics andtheir effect on health behavior can be seen in the followingdiscussions of: 1) resources and responsibilities, and 2)statuses.
A range of medical conditions could affectmembers of a household, including headaches, diarrhea, anemia,diabetes, hernias, goiters, cancer, as well as traumas like caraccidents, falls, shootings or stab wounds. With each conditioncomes shifts in resources and responsibilities as members cope withboth the unexpected and chronic situations. Caretakers attend to thepatient through examinations, diagnoses, and treatments. Householdresponsibilities are adjusted accordingly.
Several of the adjustments that may beinvolved when dealing with illness can be seen in the case of a girlwho was in the Pediatrics Ward with a lung condition. Her mother wasstaying in the room with her. They had been in the hospital almost amonth. The father was staying in a nearby hotel. The remainingthree daughters and three sons were at home in the village. Theoldest daughter, twelve years old, was now responsible for things athome, including cooking and taking care of the animals.
A second example demonstrates thecaretaker's role, which may be overlooked when focusing only on thepatient. A twelve-year-old boy was in the hospital for renalfailure. His mother was busy in their house four hours away, so hisslightly older sister was staying with him. While food is providedby the hospital, the sister brought fruit and bottled water fromoutside. She also read to her brother from the Quran and otherbooks.
As the above examples indicate, a medicalcondition necessitates a variety of changes in a household. Indeed,the full extent of the resources and responsibilities which need tobe negotiated may not be recognized by outside observers. Theseinclude fees for medications, analyses and examinations,transportation costs, arrangements for accompaniment, and the loss ofa worker and more likely of two workers either in wages or housework. All of these factors, and no doubt more, can influence health-careseeking decisions.
A consideration of the impact of a medicalcondition to the household helps explain why patients may come to thehospital too late for treatment. Looking at just one of the aspectsinvolved, that of transportation, demonstrates barriers to seekingmedical assistance. Transportation arrangements could involvecomplicated logistics, like with the one woman who was from a villagewhere to go to Sanaa, one has to walk for two hours to the road andthen take a car for five hours. If someone is ill, she must becarried for the two hours. As one doctor explained, since manypeople cannot readily afford transportation to the hospital, theywait until they determine that the condition is severe enough torequire the disruptions. People may try local treatments firstbefore going to the capital.
Illustrations of traumas that had occurredquite a bit prior to the patient's visit include a ten-year-old girlwho had been burned along the right side of her body three monthsearlier; a girl with a clouded retina where a needle had struck hereye a year and a half ago; a woman from a village who fractured herankle one month earlier when a zebu cow stepped on it; and atwelve-year-old boy who fell from a tree a month ago.
When patients do reach the hospital,however, they may be criticized for having waited too long fortreatment. Rather than criticizing patients for not seeking medicalcare sooner, we should consider the impediments to seeking that careand the arrangements that need to made in order to visit thehospital. Such arrangements are also required for people who live inSanaa, of course, such as with the one woman waiting at the door ofthe gynecological clinic who said that she had left her four childrenbehind a locked door to come to the clinic.
As mentioned, a member's access to healthcare is often influenced by his or her position within the household. One member may receive immediate treatment or the more prestigioustreatments, while another member may receive care only if thesymptoms are prolonged or may receive less prestigious treatments,such as home remedies. Among the characteristics influencing aperson's status within the household are his or her age, gender,generation, marital status, and work status. Because of thevariation in roles and responsibilities within a household, medicalconditions of various members affect the household differently. Theeffect may be as great as with the elderly man who expressed hisworry to the doctor that he had six daughters, was afraid he wasgoing to die, and then who would support them?
Since members' statuses within the householdvary as does the impact of their illness, then their access totreatments also differs. For instance, a woman brought her baby tothe Pediatrics Clinic for his diarrhea. She showed the doctor thesix different kinds of medicine she had for him. I remarked on thelarge quantity of medicines. She explained that while she hasdaughters, this is her only son. It appeared that she was tryingeverything to make him well. Biomedical practitioners focusing on atrauma or disease might overlook the household negotiations involvedin a patient's access to medical care, as resources andresponsibilities need to be shifted and the person's status and rolesare considered.
Furthermore, a person's position within thehousehold not only influences his or her access to medical care, butalso influences his or her sick role behavior. Thus, a high statusindividual or wage earner like the father/husband or maybe themother-in-law may receive concern and medical attention over a cough,whereas a lower-status individual, a daughter-in-law or middle sonperhaps, may have to really moan in order to appear sick enough toreceive attention. Therefore, listening not only to what patientsare saying but how they are saying it may provide insight intohousehold dynamics.
As many of the illustrations throughout thispaper have shown, a patient rarely acts alone in deciding the courseof his or her treatment. Other people are also influential in makinghealth care decisions. In addition to household members, a patient's"therapy management group" (Janzen 1987) may include friends,neighbors, and medical practitioners. Studies of the therapymanagement group examine who is involved in health care decisions,who gives advice and what kind, who makes the final decisions, andwho judges the effectiveness of the treatment. Research on therapymanagement groups in Yemen should consider the influence of women'sgatherings on therapy decisions. These regular afternoon visits thattake place in many parts of Yemen with neighboring women, friends, orrelatives may be a forum for discussing illnesses and healthbehavior.
A person's moral identity is affected byothers' perceptions of her illness and health care seeking. Much ofillness discourse is engaged in to create the impression that thespeaker is a good person. In telling a story, the speaker decideshow to present herself. She gains a sense of personal control overher self definition, as well as her life. For example, narrating thesearch for a cure may provide an ideal way to show that a mother didall she could for her sick child given her economic and socialconstraints (Early 1985, 1982). She may also recount how sheoutwitted a physician or government health service. The use of suchnarratives in Yemeni society deserves further research.
In this paper, I have presented observationsfrom a clinical setting to draw the reader's attention to thecultural context of the illness experience and the social relationsof health care seeking. I have presented medical anthropologyconcepts which enhance our understanding of these phenomena. Highlighted have been ethnophysiology and etiologies, ideas about howthe body functions and what causes illness. Additionally, I havedrawn attention to health care seeking process decisions about whatan illness is (and isn't), what treatments should be tried, and anevaluation of their efficacy. In a discussion of the householdproduction of health, I pointed out that different patients,depending on their position within a household, have differingentitlements which translate into differing abilities to make andfollow through on health care decisions. The concept of a therapymanagement group was introduced to draw attention to the many actorsinvolved in decisions about treatments which may be outside thehousehold as a structural unit. Finally, I have encouraged analysisof illness discourse, how and why people talk about illnesses andtreatments, the stories they tell, and the audiencesinvolved.
1. Quoting Musallam (1983). Delaney (1991:48) finds that Musallam does not "persuasivelydocument" that the Islamic attitude towards sexual generation is thatthe father and mother are equal contributors. Monogenesis, where menare believed to be the creators of children, may be the morewidespread view. It has appeared in works on Turkey (Delaney 1991),Iran (Good 1980), Morocco (Crapanzano 1973:48-49), and Egypt (Inhorn(1994).