02779536192 $5.00 + 0.00 Copyright 0 1992 Pergamon Press Ltd
Sot. Sci. Med. Vol. 35, No. 2, pp. 183-188, 1992 Printed in Great Britain. All rights reserved
FROM
ILLNESS
TO SYMBOL
AND
SYMBOL
TO ILLNESS
RICHARD W. LIEBAN Department
of Anthropology,
University
of Hawaii,
Honolulu,
HI 96822, U.S.A.
Abstract-This paper explores two aspects of the relationship between illness and social symbols: one in which illnesses become symbols; the other, in which symbols become implicated in processesthat eventuate in illness. Illness is first discussed as a symbol of social beliefs, attitudes, norms, values, and other social phenomena conceptualized in relation to them. This symbolization is analyzed as it relates to various dimensions of illness that lend themselves to figurative thinking. The paper then turns to processes through which social symbols may generate illness. In this regard, ways in which social symbols may attract people to behavior that puts their health at risk are discussed. The paper concludes with an analysis of how the development of illness may be affected by the relationship between social symbols and somatization. Key words-illness,
symbol,
social
and about the body are useful in sustaining particular views of society and social relations.” At that point in their paper, the authors discuss the body as an instrument available to human thought. But the title of their paper is ‘The Mindful Body,’ which obviously expresses concern with the body as more than a symbolic object and epitomizes their rejection of a Cartesian dichotomy between mind and body. Exemplifying their conception of a “mindful body” is their reference to sickness as “a form of communicationthe language of the organs-through which nature, society and culture speak simultaneously.” Our discussion at this juncture points the way toward a basic problem in the social symbolism of illness, a problem that concerns the relationship between meaning and epidemiology. When we speak of the symbolization of illness, are we only referring to what illness represents at the time it is perceived, the interpretation of a malady as or after it appears? Or are we also interested in how social symbols may be implicated in bringing about illnesses? As we shall see, illness is sometimes portrayed as a communicative response to social stimuli, raising the question of whether, or how, illness not only can express symbolic meaning, but also can be a consequence of it. Under the circumstances, symbolic meaning as a possible source of illness will be one of the major problems we address in discussing the relationship between illness, symbol and society. But first, since symbolic meaning is pivotal to the whole discussion, let us consider how illness may Serve as a social symbol, the kinds of meanings it can assume, and in what contexts.
In the final analysis, symbols cannot be understood only in relation to each other, but as an integral part of social, and sensual, activity [I]. In his analysis of dominant ritual symbols, Turner emphasizes ways in which such symbols link biological and social domains, representing sensual and physiological aspects of life on the one hand, and social norms and values on the other [2]. Moving from formal ritual to a wider, medical context, this association of the sensual with the social through symbolization is our focus in this paper. In certain respects, recent studies of the social meanings of illness have connections with earlier work by Turner and other anthropologists [3-61 on the body as a social symbol. However, the recently increased attention in medical anthropology to the social symbolism of illness [e.g. 7-101 undoubtedly has been given impetus by the current emphasis on interpretive studies of meaning in social and cultural anthropology at large. While the present paper is not a treatise on the nature of symbols, considering the fact that consistency is lacking in the way symbols and other semiotic terms have been defined [l 11, before proceeding it would be well to indicate how the term symbol is employed in this paper. Our usage is consistent with that of Langer [12], for whom a symbol is a vehicle for the conception of something [cf. 131.More specifically, in this paper our concern is with the social symbolism of illness in the sense that certain qualities of illness may come to represent or connote notions that people have about some aspect(s) of their society or their social relationships. In an important theoretical paper in medical anthropology, Scheper-Hughes and Lock [14] observe that symbolic and structural anthropologists “have demonstrated the extent to which humans find the body ‘good to think with.“’ In the same paragraph, they go on to say, “Cultural constructions of
SYMBOLIC MEANINGS OF ILLNESS
As a symbol of social beliefs, attitudes, norms, values and other social phenomena conceptualized in relation to them, illness has various characteristics that may lend themselves to figurative thinking about 183
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RICHARD W. LIEBAN
health problems: signs and symptoms, etiology, and social features of those who have the illness or are perceived to be particularly at risk. Sontag [15] sees the controlling metaphors in descriptions of cancer related to manifestations of the disease and drawn from the language of warfare. To illustrate, she observes that “cancer cells do not simply multiply; they are ‘invasive.’ (‘Malignant tumors invade even when they grow very slowly,’ as one textbook puts it.) Cancer cells ‘colonize’ from the original tumor to far sites of the body ..” An Asian counterpart of this translation in the West of manifestations of cancer into symbols of encroachment in social terms is reported by Nichter [16, pp. 159-1601, who observes that “cancer is used throughout South Asia as a metaphor for the invasive activities of Western capitalism and the ill effects of a Western lifestyle.” In other cases, it is etiology rather than manifestations of the illness that underlies the social symbolism of the malady. Among the Amba of East Africa, major misfortunes, including illness and death, are blamed on witchcraft. In this setting, illnesses attributed to witches are produced by personifications of evil, evil defined in terms of inversions of normal behavior in Amba society [ 171. Winter illustrates how the actions of witches are the reverse of acceptable Amba behavior in such matters as: witches go about naked. while Amba, except when in bed or bathing, are always clothed; witches can convert themselves into leopards and by “turning oneself into an animal. one can turn one’s back on human society and become a creature motivated purely by impulse and desires, unrestrained by ethical considerations”; witches eat people, while to the Amba cannibalism is morally reprehensible. In these and other respects, Winter observes that witches are inverted morally as well as physically. In this light, we can say that the etiology of illnesses blamed on witches represents the antithesis of social norms and values and accentuates their worth by identifying the horrific with violations of them. In the case above, socially disvalued qualities associated with etiology are dissociated from the victim of the illness. This is not true in other social and cultural contexts where etiology carries with it a stigma for those who contract the illness. Thus, what is popularly known as ‘stumbling disease’ exists as a unique malady among Azorean-Portuguese [18]. Behavorial symptoms closely resemble certain behavior of those under the influence of alcohol and illicit drugs, and in the United States on occasion this has led to the arrest of afflicted individuals under the misapprehension they are breaking the law. Folk explanations most commonly see incest and syphilis involved in etiology of the illness, and Boutte found that on the Azorean island of Marinhos stumbling disease, due to its perceived close link with syphilis, serves as a metaphor for sinful, immoral sexual behavior.
The etiology of AIDS has made that disease a comparable metaphor, at least in the United States and other Western areas. With AIDS, more than an etiology has loaded the stigma. Epidemiology has also contributed. The fact that in the West AIDS cases first occurred with disproportionate frequency among male homosexuals meant that not only was sexual behavior generally disapproved by society at large perceived to be implicated in the transmission of AIDS, but also a traditionally stigmatized social category, homosexual, was particularly associated with the disease [cf. 191. If AIDS, a ‘new’ disease, has been quickly freighted with a traditional social stigma, it should not be surprising that leprosy, an ‘old’ disease, called by Sontag [20] “perhaps the most stigmatized of all diseases,” has been associated with various stigmatizing phenomena during its history. In his illuminating study of leprosy, Gussow points out that after its early Biblical taint as an abomination and divine punishment for sin, the stigma of leprosy was subsequently sustained or renewed by new sources of defilement through symbolization [21]. He observes that while leprosy had virtually disappeared from Europe and its theological salience was in decline by the end of the Middle Ages, in the 19th century it was discovered to be hyperendemic in colonial areas. Consistent with the intellectual climate of the time, Europeans and Americans labeled leprosy a disease of ‘inferior’ peoples. Gussow [21, p. 191 goes on to state, “In fearing that such a disease might contaminate the ‘civilized’ world, Western nations became intensely lepraphobic by the turn of the century.” Gussow also describes how American lepraphobia was specially strengthened by a concatenation of events and attitudes regarding the Chinese: the discovery of leprosy in China; negative stereotypes of China and the Chinese; early Chinese immigration into the United States; and the perception that China was a danger to Western civilization, the ‘yellow peril’. In this kind of time perspective, the metaphoric effects of social and religious history on perceptions of leprosy were cumulatively condensed into a powerful symbol of danger and defilement. Illness as u positiae so&l
symbol
To this point we have discussed illness as a symbol of the socially disvalued. Since illness usually brings suffering, at least in some degree, it is not surprising to find unpleasant symbolic associations with illness. This, of course, is not to ignore the fact that pain can be a source of pleasure. To explore connections between pain and personal gratification as a masochistic phenomenon is beyond the purview of this paper, whose emphasis is on the social. It is quite another matter, however, to see how illness, despite its discomforts or disabilities, can be symbolically invested with positive social values.
From illness to symbol and symbol to illness
Even deadly illnesses may be identified with values prized by a group or a society. To illustrate, Sontag discusses how pulmonary tuberculosis in the 19th century was romanticized as an edifying and refined disease. “For snobs and parvenus and social climbers, TB was one index of being genteel, delicate, sensitive” [ 15, p. 281. In this case, certain signs and symptoms of the disease-such as emaciation, languour and paleness-became metaphors for social graces. In contrast, in other cases etiology rather than manifestations of the illness may symbolically associate it with what is considered to be socially desirable. In this connection, Kenny observed that in Spain attitudes toward certain illnesses were related to social class values [22, p. 2841. Thus, certain illnesses might be considered prestigious, those “thought to be caused by or associated with a surfeit of the good things in life, for instance, ulcers, gout and high blood pressure. . .” To this point, we have discussed symbols of illnesses that are prestigious. But aspects of illnesses can represent virtue as well as prestige, esteem as well as status. In this regard, let us consider bughat, a folk illness in Cebuano areas of the Philippines. The most comprehensive meaning of bughat is ‘relapse,’ and in that sense it may refer to illnesses of both men and women. However, in field research in Cebu City, all 29 cases of bughat encountered were those of women with disorders related to the female reproductive system [23]. The disorders may be menstrual, but in the great majority of cases observed they were more broadly defined, both symptomatically and etiologically. Most commonly, hughat, whose symptoms are variable, is an illness attributed in part to a special health vulnerability that all women are thought to acquire after they give birth to a child, a vulnerability produced by parturition’s wear and tear on the woman’s body. This is thought to lower permanently a woman’s resistance to illness after childbirth. This continuing susceptibility to illness combined with physical or psychological insults at a particular time produces illnesses that are diagnosed as bughat. The insults are most commonly related to a woman’s family responsibilities as wife and mother and include such factors as neglect of her own health, worry, anxiety and overwork. Given this etiology, bughat can be interpreted as a metaphor for demands and costs of the role of mother. Most of those I saw with bughat were women from poor urban households, often with several young children, and they not only had the responsibility for child care and other household tasks, but they were charged with managing the family’s extremely limited economic resources. In a typical scene I observed, when a healer attributed a patient’s bughat to irregular eating and lack of sleep and advised her to get more sleep, the patient replied how could she do that when children got sick in the night and she had to get up to take care of them, and during the day she had to do housework and watch the children to see that they did not fall.
185
A high value is placed on the role of mother in Philippine society, buttressed by traditional Filipino natalist values [24,25]. But if it is good to be a mother, cases of bughat suggest that it can be hard to be a good mother. In this perspective, symptoms of bughat can be seen as ‘wounds of virtue’.
SOCL4L SYMBOLS AS SOURCES OF ILLNESS
In this paper we are concerned with two dimensions of the relationship between social symbols and illness: symbolic features of illness that convey social meaning, and social symbols as factors that may help produce illnesses and affect their course. We concentrate on the latter dimension at this point. If social symbols are involved in the process of becoming sick, this may be through several mechanisms, one of which is health-risk behavior. Social symbols and health -risk behavior
People may behave in ways that have pathological consequences because of socially symbolic attractions of such behavior. Let us take two examples. In the United States, cigarette smoking, particularly when it comes to teenage smokers (who often become addicted for life), apparently is induced and supported by a variety of social influences. These include peer pressure and parental and family models, as well as symbolic inducements such as images of accelerated maturity and media messages that associate smoking with popularity, sexuality and social skills [26]. In this example, manifestations of the illnesses that often eventuate from the behavior are not a symbolic inducement for the behavior. In the case of anorexia nervosa apparently they can be. That is, extreme slimness, a feature of the illness which can have esthetic value, appears to be a symbolic incentive to behave in ways that may help to produce or prolong the illness. In a Canadian study, Garner and Garfinkel observe that an apparent increase in the incidence of anorexia nervosa is paralleled by a cultural esthetic preference for thinness in women [27]. They see fashion’s promotion of thinness as a symbol of beauty and success as part of cultural pressures for women to diet and assume a slim body shape. And they postulate that responses to these pressures, combined with other predisposing factors, may engender in a certain number of vulnerable adolescents morbid psychobiological processes, involving weight loss and emergence of starvation, that eventuate in and perpetuate anorexia nervosa. Consistent with this view are findings of an empirical study by Garner and Garfinkel [27] of professional dance and modelling students, who by career choice must concentrate increased attention on body shape. Anorexia nervosa and dieting concerns were overrepresented in dance and modelling students when compared with other students. Within the dance group, those from the most
186
RICHARDW. LIEBAN
competitive environments had the highest frequency of anorexia nervosa, suggesting that pressures to be thin and achievement motivation are risk factors in development of the disorder [28]. In the above examples, influences of symbols on the development of illness are postulated in ways which are consistent with conventional analytical approaches to epidemiology that study effects of behavior on the incidence of disease. One distinction between the two examples, referred to previously, is that in anorexia characteristics of the illness, or transitions toward the illness, have symbolic value for the victim; illnesses that may eventuate from smoking do not. It is value associated with symbolic features of illness as a factor in its emergence that we now want to explore more fully. But we will do so in a broader perspective than that provided by the example of anorexia. Idiomatic illnesses and somatization Various studies have analyzed illness (sickness) as an expressive medium for those who undergo it, a communication about, inter alia, social factors and their relationship to the patient [e.g. 29931, 71. As expressions of the relationship between the patient and society, illness may reflect such things as adherence to norms [32], guilt associated with deviation from them [33], or resistance to or protest against them [9, 14, 341. Illness as an expression of discontent or defiance may reach the point, as with ‘school refusal syndrome’ in Japan, where behavioral symptoms of a disorder take the form of an explicit protest against normative social expectations [35]. In regard to possible messages or metamessages of illness, our problem here is how the socially symbolic content of some of these messages may be implicated in development of illnesses that convey them. We will explore this question within the conceptual framework of somatization, defined as “the normative expression of personal and social distress in an idiom of bodily complaints and medical help-seeking” [36, p. 21. In considering how the expressiveness of some illnesses may relate to somatization, we begin with what Nichter [7, p. 3791 termed ‘idioms of distress’, referring to certain disorders among Havik Brahmin women in South India. Such disorders were defined as ethnopsychiatric phenomena “underscored by symbolic and affective associations which take on contextual meaning in relation to particular stressors.” The women studied were patients of an ayuruedic practitioner, and Nichter showed how their presenting complaints were, in terms of ethnoetiologies, symbolically linked with socially distressful circumstances. Psychosocial problems of women in cases like these were thought to: “(a) precipitate or complicate physical symptoms (as psychogenic or precipitant/ aggravating factors). (b) Cause a patient to be preoccupied with symptoms as: (1) a means of either initiating dialogue about life to ventilate feelings; and/or (2) displacing affect” [7, p. 3881.
Of comparative interest is another study, by Low [31], who found nervios (nerves), a presenting complaint, to be a symptom of family discord and disruption among urban Costa Ricans, “in a society where family is the primary source of social identity.” Common to patients complaining of nervios were undesirable body responses over which they had no control. Low ascribed stressful problems symbolized by nervios a role in etiology of the complaint, whose emergence, she observed, also provided patients with a symbolic vehicle for initiating dialogue about the problem. In their analyses, Nichter and Low consider how illnesses, or symptoms of illnesses, perceived in socially symbolic terms, provide patients an opportunity to communicate about distressful problems and thereby ameliorate them or feelings about them. In this sense, the pain brings with it a gain. The instrumental value of illness, defined in terms of benefits of illness for the sick, was an important aspect of Parsons’ analysis of the sick role, with respect to its providing a respite from pressures of social obligations [37,38]. More recently, this and other benefits that could be gained from illness were noted by Kleinman [36] in connection with discussion of possibly adaptive aspects of somatization in China. In the same work [36, p. 1941, with reference to somatization, Kleinman observed that there had been little research on how “bodily meanings become an intimate, sociophysiological part of bodily processes.” However, as Kleinman elucidates in the work cited, somatization is not simply a function of somatic processes in the conversion of distress into bodily symptoms. As Kirmayer [39] has noted, social and psychological processes that affect the perception and assessment of sensations and the expression of feelings are also entailed. In addition to considering somatic processes, therefore, one can examine somatization in relation to sociopsychological factors influencing responses to sensations as, or after, they are experienced. More specifically, such sociopsychological factors, as aspects of somatization, can be analyzed as they bear on our focal problem in this part of the paper: how symbolic inducements to being ill can affect becoming ill. To illustrate, let us return to the Philippine folk illness, bughat. The reader may remember the putative symbolic value of this illness for patients, in its representation of costs of motherhood and the dedicated willingness of mothers to bear them. The ethnoetiology of bughat, stressful social circumstances of those who contract it (often women from poor households, with demanding, frequently difficult family roles), and the discourse between healers and patients diagnosed with the ailment suggest a relationship between the symbolic value of bughat and development of it by some patients. Somatization in such cases would involve attention to and assessment of body states as or after they are experienced.
From
illness to symbol
These cognitive aspects of bughar are our concern at this point, particularly in certain borderline cases, where the decision of the patient to be a patient is problematic. For example, two women diagnosed by a healer as having bughat decided prior to that that they were sick, or sick enough to be treated, only after they had brought their children to the healer for medical care, a healer whose adult clientele consisted almost entirely of women, many of whom were diagnosed as having bughat [23]. In such cases where indications of possible illness are less perceptible, we would expect that prospective benefits of being ill, such as the symbolic value of bughat to the patient, might be particularly relevant factors in any propensities to become identified as ill. At this point several caveats are in order: (1) Apart from the influence of symbolic benefits we have been discussing, in some cases of bughat noxious psychophysiological effects of distress may be involved in development of the illness. In general terms, neither of the two explanations invalidates the other. Nor are they necessarily mutually exclusive with reference to particular cases. To illustrate, in some bughat cases somatization may involve amplified attention to existing symptoms that are linked to psychogenic stressors. (2) Bughat is an illness with diverse symptoms of varying severity, and in an analysis of this kind there is a danger of the observer trivializing suffering by converting it into a strategy. Our contention is not that suffering can be viewed as a secondary consideration for patients who experience it, or that benefits they might derive from the illness are simply and directly calculated by the patient in advance. That may be so in some cases, but in most we suggest that the cognitive and emotional factors entailed are more complex and subtle, and the process more contingent than a set strategy would imply. In this regard, Kleinman [36, p. 1511, discussing adaptive aspects of somatization for the sick, observes, “This does not mean that we malinger or that we rationally choose to somatize.” Health and illness constitute a continuum, and when one becomes the other is often vague [40-42]. In this connection, Kirmayer [43], quoted in Parsons and Wakely [44, pp. 112-l 131, observes, “The definition of discrete disorders remains an artifact of sometimes arbitrary critera that leave the milder and intermediate forms of distress ambiguous.” These considerations, particularly in borderline cases, emphasize the importance of subjective factors and negotiation of his health status with others in the individual’s becoming recognizably ill. In the process, various social factors can be potential influences on the perception of and discourse about altered body sensations or appearances as symptomatic of illness. One of these factors, the instrumental value of being ill, has occupied our attention in the last section of the paper, with special emphasis on the question of how symbolic benefits of certain illnesses may be an influence in their development.
and symbol
to illness
187 CONCLUSION
In broad terms, symbolic dimensions of illness can be seen as pervasive in the relationship of illness to its sociocultural setting. To illustrate, Kleinman [45, p. 2081 in writing about the symbolic reality of medicine, asserts that a medical system, including nosologies, interpretations and treatments of illness, “is an important part of the cultural world and as such is constructed, like any other segment of social reality, by the regnant body of social meanings.” This emphasis on the symbolic in the overall social and cultural context of illness is consistent with White’s [46] view of culture as a symbolic product, or with the recent trend in anthropology “toward conceiving of social life as organized in terms of symbols. whose meaning we must grasp if we are to understand that organization and formulate its principles. . .” [47, p. 211. In this perspective, the beliefs, norms, attitudes, values and other associated social phenomena that have concerned us are symbolic phenomena in their own right. However, in this paper we have employed the term symbol in a more restricted sense, as a vehicle of signification. While they are grounded in the human ability to symbolize and they can be analyzed in terms of their symbolic content, in this paper beliefs, norms, attitudes, values, and other social phenomena defined in connection with them are primarily of interest as conceptual features of society and social relations, and the use of symbol has concentrated on the semiotic linkage between illness and these social conceptions. Our purpose in this essay has not been, by implication, to slight the importance of biological aspects of affliction and the influence of material conditions of life on health. However, if illness is regarded as the experience of disvalued states of health [48,49], symbolic dimensions of that experience require attention in characterizing illness. That characterization can, as it has in this paper, encompass the relationship between illness and social symbols in two respects: one in which illnesses become social symbols, and the other in which social symbols become implicated in processes that eventuate in illness. This dualistic approach to the symbolic articulation between illness and society reflects two basic problems whose investigation falls within the purview of the relationship between the social sciences and medicine: one concerns the influence of social features on health and responses to health problems; the other, how medical phenomena can illuminate characteristics of society. Acknowledgements-1 am grateful to Jack Bilmes, George Grace, and two anonymous reviewers for helpful comments at various stages in preparation of the final version of this paper. REFERENCES
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Sot. Sci. Med. Vol. 35, No. 2, pp. 183-188, 1992 Printed in Great Britain. All rights reserved
FROM
ILLNESS
TO SYMBOL
AND
SYMBOL
TO ILLNESS
RICHARD W. LIEBAN Department
of Anthropology,
University
of Hawaii,
Honolulu,
HI 96822, U.S.A.
Abstract-This paper explores two aspects of the relationship between illness and social symbols: one in which illnesses become symbols; the other, in which symbols become implicated in processesthat eventuate in illness. Illness is first discussed as a symbol of social beliefs, attitudes, norms, values, and other social phenomena conceptualized in relation to them. This symbolization is analyzed as it relates to various dimensions of illness that lend themselves to figurative thinking. The paper then turns to processes through which social symbols may generate illness. In this regard, ways in which social symbols may attract people to behavior that puts their health at risk are discussed. The paper concludes with an analysis of how the development of illness may be affected by the relationship between social symbols and somatization. Key words-illness,
symbol,
social
and about the body are useful in sustaining particular views of society and social relations.” At that point in their paper, the authors discuss the body as an instrument available to human thought. But the title of their paper is ‘The Mindful Body,’ which obviously expresses concern with the body as more than a symbolic object and epitomizes their rejection of a Cartesian dichotomy between mind and body. Exemplifying their conception of a “mindful body” is their reference to sickness as “a form of communicationthe language of the organs-through which nature, society and culture speak simultaneously.” Our discussion at this juncture points the way toward a basic problem in the social symbolism of illness, a problem that concerns the relationship between meaning and epidemiology. When we speak of the symbolization of illness, are we only referring to what illness represents at the time it is perceived, the interpretation of a malady as or after it appears? Or are we also interested in how social symbols may be implicated in bringing about illnesses? As we shall see, illness is sometimes portrayed as a communicative response to social stimuli, raising the question of whether, or how, illness not only can express symbolic meaning, but also can be a consequence of it. Under the circumstances, symbolic meaning as a possible source of illness will be one of the major problems we address in discussing the relationship between illness, symbol and society. But first, since symbolic meaning is pivotal to the whole discussion, let us consider how illness may Serve as a social symbol, the kinds of meanings it can assume, and in what contexts.
In the final analysis, symbols cannot be understood only in relation to each other, but as an integral part of social, and sensual, activity [I]. In his analysis of dominant ritual symbols, Turner emphasizes ways in which such symbols link biological and social domains, representing sensual and physiological aspects of life on the one hand, and social norms and values on the other [2]. Moving from formal ritual to a wider, medical context, this association of the sensual with the social through symbolization is our focus in this paper. In certain respects, recent studies of the social meanings of illness have connections with earlier work by Turner and other anthropologists [3-61 on the body as a social symbol. However, the recently increased attention in medical anthropology to the social symbolism of illness [e.g. 7-101 undoubtedly has been given impetus by the current emphasis on interpretive studies of meaning in social and cultural anthropology at large. While the present paper is not a treatise on the nature of symbols, considering the fact that consistency is lacking in the way symbols and other semiotic terms have been defined [l 11, before proceeding it would be well to indicate how the term symbol is employed in this paper. Our usage is consistent with that of Langer [12], for whom a symbol is a vehicle for the conception of something [cf. 131.More specifically, in this paper our concern is with the social symbolism of illness in the sense that certain qualities of illness may come to represent or connote notions that people have about some aspect(s) of their society or their social relationships. In an important theoretical paper in medical anthropology, Scheper-Hughes and Lock [14] observe that symbolic and structural anthropologists “have demonstrated the extent to which humans find the body ‘good to think with.“’ In the same paragraph, they go on to say, “Cultural constructions of
SYMBOLIC MEANINGS OF ILLNESS
As a symbol of social beliefs, attitudes, norms, values and other social phenomena conceptualized in relation to them, illness has various characteristics that may lend themselves to figurative thinking about 183
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health problems: signs and symptoms, etiology, and social features of those who have the illness or are perceived to be particularly at risk. Sontag [15] sees the controlling metaphors in descriptions of cancer related to manifestations of the disease and drawn from the language of warfare. To illustrate, she observes that “cancer cells do not simply multiply; they are ‘invasive.’ (‘Malignant tumors invade even when they grow very slowly,’ as one textbook puts it.) Cancer cells ‘colonize’ from the original tumor to far sites of the body ..” An Asian counterpart of this translation in the West of manifestations of cancer into symbols of encroachment in social terms is reported by Nichter [16, pp. 159-1601, who observes that “cancer is used throughout South Asia as a metaphor for the invasive activities of Western capitalism and the ill effects of a Western lifestyle.” In other cases, it is etiology rather than manifestations of the illness that underlies the social symbolism of the malady. Among the Amba of East Africa, major misfortunes, including illness and death, are blamed on witchcraft. In this setting, illnesses attributed to witches are produced by personifications of evil, evil defined in terms of inversions of normal behavior in Amba society [ 171. Winter illustrates how the actions of witches are the reverse of acceptable Amba behavior in such matters as: witches go about naked. while Amba, except when in bed or bathing, are always clothed; witches can convert themselves into leopards and by “turning oneself into an animal. one can turn one’s back on human society and become a creature motivated purely by impulse and desires, unrestrained by ethical considerations”; witches eat people, while to the Amba cannibalism is morally reprehensible. In these and other respects, Winter observes that witches are inverted morally as well as physically. In this light, we can say that the etiology of illnesses blamed on witches represents the antithesis of social norms and values and accentuates their worth by identifying the horrific with violations of them. In the case above, socially disvalued qualities associated with etiology are dissociated from the victim of the illness. This is not true in other social and cultural contexts where etiology carries with it a stigma for those who contract the illness. Thus, what is popularly known as ‘stumbling disease’ exists as a unique malady among Azorean-Portuguese [18]. Behavorial symptoms closely resemble certain behavior of those under the influence of alcohol and illicit drugs, and in the United States on occasion this has led to the arrest of afflicted individuals under the misapprehension they are breaking the law. Folk explanations most commonly see incest and syphilis involved in etiology of the illness, and Boutte found that on the Azorean island of Marinhos stumbling disease, due to its perceived close link with syphilis, serves as a metaphor for sinful, immoral sexual behavior.
The etiology of AIDS has made that disease a comparable metaphor, at least in the United States and other Western areas. With AIDS, more than an etiology has loaded the stigma. Epidemiology has also contributed. The fact that in the West AIDS cases first occurred with disproportionate frequency among male homosexuals meant that not only was sexual behavior generally disapproved by society at large perceived to be implicated in the transmission of AIDS, but also a traditionally stigmatized social category, homosexual, was particularly associated with the disease [cf. 191. If AIDS, a ‘new’ disease, has been quickly freighted with a traditional social stigma, it should not be surprising that leprosy, an ‘old’ disease, called by Sontag [20] “perhaps the most stigmatized of all diseases,” has been associated with various stigmatizing phenomena during its history. In his illuminating study of leprosy, Gussow points out that after its early Biblical taint as an abomination and divine punishment for sin, the stigma of leprosy was subsequently sustained or renewed by new sources of defilement through symbolization [21]. He observes that while leprosy had virtually disappeared from Europe and its theological salience was in decline by the end of the Middle Ages, in the 19th century it was discovered to be hyperendemic in colonial areas. Consistent with the intellectual climate of the time, Europeans and Americans labeled leprosy a disease of ‘inferior’ peoples. Gussow [21, p. 191 goes on to state, “In fearing that such a disease might contaminate the ‘civilized’ world, Western nations became intensely lepraphobic by the turn of the century.” Gussow also describes how American lepraphobia was specially strengthened by a concatenation of events and attitudes regarding the Chinese: the discovery of leprosy in China; negative stereotypes of China and the Chinese; early Chinese immigration into the United States; and the perception that China was a danger to Western civilization, the ‘yellow peril’. In this kind of time perspective, the metaphoric effects of social and religious history on perceptions of leprosy were cumulatively condensed into a powerful symbol of danger and defilement. Illness as u positiae so&l
symbol
To this point we have discussed illness as a symbol of the socially disvalued. Since illness usually brings suffering, at least in some degree, it is not surprising to find unpleasant symbolic associations with illness. This, of course, is not to ignore the fact that pain can be a source of pleasure. To explore connections between pain and personal gratification as a masochistic phenomenon is beyond the purview of this paper, whose emphasis is on the social. It is quite another matter, however, to see how illness, despite its discomforts or disabilities, can be symbolically invested with positive social values.
From illness to symbol and symbol to illness
Even deadly illnesses may be identified with values prized by a group or a society. To illustrate, Sontag discusses how pulmonary tuberculosis in the 19th century was romanticized as an edifying and refined disease. “For snobs and parvenus and social climbers, TB was one index of being genteel, delicate, sensitive” [ 15, p. 281. In this case, certain signs and symptoms of the disease-such as emaciation, languour and paleness-became metaphors for social graces. In contrast, in other cases etiology rather than manifestations of the illness may symbolically associate it with what is considered to be socially desirable. In this connection, Kenny observed that in Spain attitudes toward certain illnesses were related to social class values [22, p. 2841. Thus, certain illnesses might be considered prestigious, those “thought to be caused by or associated with a surfeit of the good things in life, for instance, ulcers, gout and high blood pressure. . .” To this point, we have discussed symbols of illnesses that are prestigious. But aspects of illnesses can represent virtue as well as prestige, esteem as well as status. In this regard, let us consider bughat, a folk illness in Cebuano areas of the Philippines. The most comprehensive meaning of bughat is ‘relapse,’ and in that sense it may refer to illnesses of both men and women. However, in field research in Cebu City, all 29 cases of bughat encountered were those of women with disorders related to the female reproductive system [23]. The disorders may be menstrual, but in the great majority of cases observed they were more broadly defined, both symptomatically and etiologically. Most commonly, hughat, whose symptoms are variable, is an illness attributed in part to a special health vulnerability that all women are thought to acquire after they give birth to a child, a vulnerability produced by parturition’s wear and tear on the woman’s body. This is thought to lower permanently a woman’s resistance to illness after childbirth. This continuing susceptibility to illness combined with physical or psychological insults at a particular time produces illnesses that are diagnosed as bughat. The insults are most commonly related to a woman’s family responsibilities as wife and mother and include such factors as neglect of her own health, worry, anxiety and overwork. Given this etiology, bughat can be interpreted as a metaphor for demands and costs of the role of mother. Most of those I saw with bughat were women from poor urban households, often with several young children, and they not only had the responsibility for child care and other household tasks, but they were charged with managing the family’s extremely limited economic resources. In a typical scene I observed, when a healer attributed a patient’s bughat to irregular eating and lack of sleep and advised her to get more sleep, the patient replied how could she do that when children got sick in the night and she had to get up to take care of them, and during the day she had to do housework and watch the children to see that they did not fall.
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A high value is placed on the role of mother in Philippine society, buttressed by traditional Filipino natalist values [24,25]. But if it is good to be a mother, cases of bughat suggest that it can be hard to be a good mother. In this perspective, symptoms of bughat can be seen as ‘wounds of virtue’.
SOCL4L SYMBOLS AS SOURCES OF ILLNESS
In this paper we are concerned with two dimensions of the relationship between social symbols and illness: symbolic features of illness that convey social meaning, and social symbols as factors that may help produce illnesses and affect their course. We concentrate on the latter dimension at this point. If social symbols are involved in the process of becoming sick, this may be through several mechanisms, one of which is health-risk behavior. Social symbols and health -risk behavior
People may behave in ways that have pathological consequences because of socially symbolic attractions of such behavior. Let us take two examples. In the United States, cigarette smoking, particularly when it comes to teenage smokers (who often become addicted for life), apparently is induced and supported by a variety of social influences. These include peer pressure and parental and family models, as well as symbolic inducements such as images of accelerated maturity and media messages that associate smoking with popularity, sexuality and social skills [26]. In this example, manifestations of the illnesses that often eventuate from the behavior are not a symbolic inducement for the behavior. In the case of anorexia nervosa apparently they can be. That is, extreme slimness, a feature of the illness which can have esthetic value, appears to be a symbolic incentive to behave in ways that may help to produce or prolong the illness. In a Canadian study, Garner and Garfinkel observe that an apparent increase in the incidence of anorexia nervosa is paralleled by a cultural esthetic preference for thinness in women [27]. They see fashion’s promotion of thinness as a symbol of beauty and success as part of cultural pressures for women to diet and assume a slim body shape. And they postulate that responses to these pressures, combined with other predisposing factors, may engender in a certain number of vulnerable adolescents morbid psychobiological processes, involving weight loss and emergence of starvation, that eventuate in and perpetuate anorexia nervosa. Consistent with this view are findings of an empirical study by Garner and Garfinkel [27] of professional dance and modelling students, who by career choice must concentrate increased attention on body shape. Anorexia nervosa and dieting concerns were overrepresented in dance and modelling students when compared with other students. Within the dance group, those from the most
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competitive environments had the highest frequency of anorexia nervosa, suggesting that pressures to be thin and achievement motivation are risk factors in development of the disorder [28]. In the above examples, influences of symbols on the development of illness are postulated in ways which are consistent with conventional analytical approaches to epidemiology that study effects of behavior on the incidence of disease. One distinction between the two examples, referred to previously, is that in anorexia characteristics of the illness, or transitions toward the illness, have symbolic value for the victim; illnesses that may eventuate from smoking do not. It is value associated with symbolic features of illness as a factor in its emergence that we now want to explore more fully. But we will do so in a broader perspective than that provided by the example of anorexia. Idiomatic illnesses and somatization Various studies have analyzed illness (sickness) as an expressive medium for those who undergo it, a communication about, inter alia, social factors and their relationship to the patient [e.g. 29931, 71. As expressions of the relationship between the patient and society, illness may reflect such things as adherence to norms [32], guilt associated with deviation from them [33], or resistance to or protest against them [9, 14, 341. Illness as an expression of discontent or defiance may reach the point, as with ‘school refusal syndrome’ in Japan, where behavioral symptoms of a disorder take the form of an explicit protest against normative social expectations [35]. In regard to possible messages or metamessages of illness, our problem here is how the socially symbolic content of some of these messages may be implicated in development of illnesses that convey them. We will explore this question within the conceptual framework of somatization, defined as “the normative expression of personal and social distress in an idiom of bodily complaints and medical help-seeking” [36, p. 21. In considering how the expressiveness of some illnesses may relate to somatization, we begin with what Nichter [7, p. 3791 termed ‘idioms of distress’, referring to certain disorders among Havik Brahmin women in South India. Such disorders were defined as ethnopsychiatric phenomena “underscored by symbolic and affective associations which take on contextual meaning in relation to particular stressors.” The women studied were patients of an ayuruedic practitioner, and Nichter showed how their presenting complaints were, in terms of ethnoetiologies, symbolically linked with socially distressful circumstances. Psychosocial problems of women in cases like these were thought to: “(a) precipitate or complicate physical symptoms (as psychogenic or precipitant/ aggravating factors). (b) Cause a patient to be preoccupied with symptoms as: (1) a means of either initiating dialogue about life to ventilate feelings; and/or (2) displacing affect” [7, p. 3881.
Of comparative interest is another study, by Low [31], who found nervios (nerves), a presenting complaint, to be a symptom of family discord and disruption among urban Costa Ricans, “in a society where family is the primary source of social identity.” Common to patients complaining of nervios were undesirable body responses over which they had no control. Low ascribed stressful problems symbolized by nervios a role in etiology of the complaint, whose emergence, she observed, also provided patients with a symbolic vehicle for initiating dialogue about the problem. In their analyses, Nichter and Low consider how illnesses, or symptoms of illnesses, perceived in socially symbolic terms, provide patients an opportunity to communicate about distressful problems and thereby ameliorate them or feelings about them. In this sense, the pain brings with it a gain. The instrumental value of illness, defined in terms of benefits of illness for the sick, was an important aspect of Parsons’ analysis of the sick role, with respect to its providing a respite from pressures of social obligations [37,38]. More recently, this and other benefits that could be gained from illness were noted by Kleinman [36] in connection with discussion of possibly adaptive aspects of somatization in China. In the same work [36, p. 1941, with reference to somatization, Kleinman observed that there had been little research on how “bodily meanings become an intimate, sociophysiological part of bodily processes.” However, as Kleinman elucidates in the work cited, somatization is not simply a function of somatic processes in the conversion of distress into bodily symptoms. As Kirmayer [39] has noted, social and psychological processes that affect the perception and assessment of sensations and the expression of feelings are also entailed. In addition to considering somatic processes, therefore, one can examine somatization in relation to sociopsychological factors influencing responses to sensations as, or after, they are experienced. More specifically, such sociopsychological factors, as aspects of somatization, can be analyzed as they bear on our focal problem in this part of the paper: how symbolic inducements to being ill can affect becoming ill. To illustrate, let us return to the Philippine folk illness, bughat. The reader may remember the putative symbolic value of this illness for patients, in its representation of costs of motherhood and the dedicated willingness of mothers to bear them. The ethnoetiology of bughat, stressful social circumstances of those who contract it (often women from poor households, with demanding, frequently difficult family roles), and the discourse between healers and patients diagnosed with the ailment suggest a relationship between the symbolic value of bughat and development of it by some patients. Somatization in such cases would involve attention to and assessment of body states as or after they are experienced.
From
illness to symbol
These cognitive aspects of bughar are our concern at this point, particularly in certain borderline cases, where the decision of the patient to be a patient is problematic. For example, two women diagnosed by a healer as having bughat decided prior to that that they were sick, or sick enough to be treated, only after they had brought their children to the healer for medical care, a healer whose adult clientele consisted almost entirely of women, many of whom were diagnosed as having bughat [23]. In such cases where indications of possible illness are less perceptible, we would expect that prospective benefits of being ill, such as the symbolic value of bughat to the patient, might be particularly relevant factors in any propensities to become identified as ill. At this point several caveats are in order: (1) Apart from the influence of symbolic benefits we have been discussing, in some cases of bughat noxious psychophysiological effects of distress may be involved in development of the illness. In general terms, neither of the two explanations invalidates the other. Nor are they necessarily mutually exclusive with reference to particular cases. To illustrate, in some bughat cases somatization may involve amplified attention to existing symptoms that are linked to psychogenic stressors. (2) Bughat is an illness with diverse symptoms of varying severity, and in an analysis of this kind there is a danger of the observer trivializing suffering by converting it into a strategy. Our contention is not that suffering can be viewed as a secondary consideration for patients who experience it, or that benefits they might derive from the illness are simply and directly calculated by the patient in advance. That may be so in some cases, but in most we suggest that the cognitive and emotional factors entailed are more complex and subtle, and the process more contingent than a set strategy would imply. In this regard, Kleinman [36, p. 1511, discussing adaptive aspects of somatization for the sick, observes, “This does not mean that we malinger or that we rationally choose to somatize.” Health and illness constitute a continuum, and when one becomes the other is often vague [40-42]. In this connection, Kirmayer [43], quoted in Parsons and Wakely [44, pp. 112-l 131, observes, “The definition of discrete disorders remains an artifact of sometimes arbitrary critera that leave the milder and intermediate forms of distress ambiguous.” These considerations, particularly in borderline cases, emphasize the importance of subjective factors and negotiation of his health status with others in the individual’s becoming recognizably ill. In the process, various social factors can be potential influences on the perception of and discourse about altered body sensations or appearances as symptomatic of illness. One of these factors, the instrumental value of being ill, has occupied our attention in the last section of the paper, with special emphasis on the question of how symbolic benefits of certain illnesses may be an influence in their development.
and symbol
to illness
187 CONCLUSION
In broad terms, symbolic dimensions of illness can be seen as pervasive in the relationship of illness to its sociocultural setting. To illustrate, Kleinman [45, p. 2081 in writing about the symbolic reality of medicine, asserts that a medical system, including nosologies, interpretations and treatments of illness, “is an important part of the cultural world and as such is constructed, like any other segment of social reality, by the regnant body of social meanings.” This emphasis on the symbolic in the overall social and cultural context of illness is consistent with White’s [46] view of culture as a symbolic product, or with the recent trend in anthropology “toward conceiving of social life as organized in terms of symbols. whose meaning we must grasp if we are to understand that organization and formulate its principles. . .” [47, p. 211. In this perspective, the beliefs, norms, attitudes, values and other associated social phenomena that have concerned us are symbolic phenomena in their own right. However, in this paper we have employed the term symbol in a more restricted sense, as a vehicle of signification. While they are grounded in the human ability to symbolize and they can be analyzed in terms of their symbolic content, in this paper beliefs, norms, attitudes, values, and other social phenomena defined in connection with them are primarily of interest as conceptual features of society and social relations, and the use of symbol has concentrated on the semiotic linkage between illness and these social conceptions. Our purpose in this essay has not been, by implication, to slight the importance of biological aspects of affliction and the influence of material conditions of life on health. However, if illness is regarded as the experience of disvalued states of health [48,49], symbolic dimensions of that experience require attention in characterizing illness. That characterization can, as it has in this paper, encompass the relationship between illness and social symbols in two respects: one in which illnesses become social symbols, and the other in which social symbols become implicated in processes that eventuate in illness. This dualistic approach to the symbolic articulation between illness and society reflects two basic problems whose investigation falls within the purview of the relationship between the social sciences and medicine: one concerns the influence of social features on health and responses to health problems; the other, how medical phenomena can illuminate characteristics of society. Acknowledgements-1 am grateful to Jack Bilmes, George Grace, and two anonymous reviewers for helpful comments at various stages in preparation of the final version of this paper. REFERENCES
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