blumhagen - 1980 - hyper-tension a folk illness with a medical name

7/27/2019 Blumhagen - 1980 - Hyper-Tension a Folk Illness With a Medical Name

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D A N B L U M H A G E N

H Y P E R - T E N S I O N : A F O L K I L L N E S S W l T H A M E D I C A LN A M E t

ABSTRACT. Individual il lness bel ief systems form a cognit ive s t ructure w hich l ies bene aththe cul tural and social aspect of h eal th care in a com mu ni ty . Popu lar bel ief systems aredi f ferent f rom , y et l inked to , exp er t bel ief systems. Popular il lness terms of ten h elp supp or ta s table cul tural mi l ieu by l inking concepts of causes and signi f icance of types of i l lnessproblem s w i th a set o f he al th care seeking choices; as wel l as linking typic al physical andpsycho logical sym ptom s wi th associated social problems . This s tudy presents an exam ple ofhow i llness bel iefs per form these func t ions in urban , m ainst ream Amer ica.One hund red an d seventeen peop le wi th biom edical ly def ined hype r tension were in ter -viewed fol lowing the E xplan atory Models format . The b el ief held by 72% of th is sample wasthat they had 'Hyp er-Tens ion, ' a physical i llness character ized by excessive nervousnesscaused by untow ard social s t ress. The d ata are used to der ive a com posi te d iagram of thecognit ive d om ain of 'Hyp er-Ten sion ' in Am er ica which d emo nst rates the var ious opt ion speople have for in terp ret ing thei r exper iences and choosing ap prop r ia te therap eut ic act ions.They use th is i llness bel ief system to ju st i fy otherwise unw arranted social behavior and toassume var ious aspects of the s ick role . This popular m ode l i s compared and contrasted w i ththe professional model of the disease 'hyper tension ' and wi th other less f requent modelswhich were observed in th is sample.

I N T R O D U C T I O NI t i s g e n e r a l l y a c c e p t e d t h a t a l l c u l t u r e s h a v e s o m e s o r t o f h e a l i n g t r a d i t i o n . H o wt h e s e d i f f e ri n g h e a l in g s y s t e m s f u n c t i o n t o m a i n t a i n a s t a b le c u l t u r a l m i l i e u isa m a t t e r o f m u c h w i d e r d e b a t e . F r e q u e n t l y h e a l in g s y st e m s a re d i v id e d i n t oc a t e g o r i e s s u c h a s : l o c a l ( p r i m i t i v e , f o l k ) m e d i c a l s y s t e m ; r e g i o n a l ( A y u r v e d i c ,U n a n i , C h i n e s e ) m e d i c a l s y s t e m s a n d t h e c o s m o p o l i t a n ( m o d e r n , W e s t er n ,s c i e n t if i c ) m e d i c a l s y s t e m . T h i s t y p e o f c l a s s i f ic a t i o n r e li e s o n d i f f e r e n c e s i ng e o g r a p h i c s p r e a d , d e g r e e o f p r o f e s s i o n a l i z a t i o n , a n d u n d e r l y i n g t h e o r i e s o fh e a l t h , d i s ea s e a n d h e a l i n g . S i n c e t h i s t y p e o f an a l y s i s t e n d s t o s t re s s d if f e r e n c e sr a t h e r t h a n c o m m o n a l i t i e s , fu n c t i o n a l e q u i v a le n t s w h i c h o c c u r a c ro s s m e d i c a ls y s te m s a r e m o r e d i f fi c u lt t o d e t e r m i n e ( P r es s 1 9 8 0 ). T h e t y p e o f p r o b l e m t h a td e v e l o p s i s i l lu s t r a t e d b y P r e s s w h o d e f i n e s a f o l k m e d i c a l s y s t e m a s b e i n g ( 1 )a n y h e a l t h s y s t e m a t v a r i a n c e w i t h W e s t e r n , s c i e n t i fi c m e d i c i n e ; ( 2 ) a n y h e a l t hs y s t e m a t v a r ia n c e w i t h a c o d i f i e d , f o r m a l a n d l i t e r a t e m e d i c a l t r a d i t i o n ( W e s t e r n ,s c i e n t if i c , A y u r v e d i c , c l a s s ic a l C h i n e s e , e t c . ) ; ( 3 ) a n y s y s t e m o f h e a l t h p r a c t i c ea t v a r i a n ce w i t h t h e o f f ic i a l h e a l t h p r a c t i c e o f th e c o m m u n i t y o r n a t i o n ( P r es s1 9 7 8 ) . T h i s t y p e o f t h e o r e t i c a l m u d d l e a r is e s b e c a u s e r e s e a r c h e rs a l l o w t h e m -s e lv e s t o b e d i s t r a c t e d b y d i f f e r e n c e s in h e a l i n g t h e o r y ( e .g . , b i o m e d i c a l v s.A y u r v e d i c ) o r i n r i t u a l p r a c t i c e s ( n a t u r a l is t i c v s. s p i r it u a l i s t ic ) o r i n a p p a r e n tc o m p l e x i t y ( c o s m o p o l i t a n v s . l o c a l) . H o r t o n h a s d o c u m e n t e d t h a t , i n f a c t , t h e s e

Culture, Medicine and Psychiatry 4 ( 1 9 8 0 ) 1 9 7 - 2 2 7 . 0 1 6 5 - 0 0 5 X / 8 0 / 0 0 4 3 - 0 1 9 7 $ 0 3 . 1 0 .Copyright 1980 by D. Reidel Publishing Co., Dordrecht, Holland, and Boston, U.S.A.


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1 9 8 D A N B L U M H A G E Ndi f f e r ences m ay be m or e appa r en t t han r ea l, even w h en A f r ican tr ad i t i ona l t hou gh tand W es te r n s c ience ar e con t r a s t ed ( 196 7) . Pe r haps a m or e f r u i t f u l w ay t oappr oac h a t heo r e t i c a l unde r s t and i ng o f hea l t h ca r e sys t em s is t o l o ok a t t hed i s t r ibu t i on o f hea l ing know l edge i n a cu l t u r e , and t hen exam i ne how t h i sknowledge i s used to shape both soc ia l and persona l rea l i t i es .

O ne o f t he cha r ac t er i st i c s o f nea r l y a ll hea l t h ca r e sys t em s is t ha t t he r e i s ad i v i s i on o f know l edge i n t o p r ac t i t i one r ( o r p r o f e s s i ona l ) and popu l a r r ea l m s .Whil e t h is i s show n i n com pl ex , u r b an env i r onm en t s , i t p r ob ab l y a l so app li e s t om ost small sca le soc ie t i es as wel l . Thus , d espi te Lew is ' c la im tha t the Gnau " don o t h a v e d e a f l y r e c o g n iz e d m e d i c al e x p e r t s " ( 1 9 7 5 : 1 9 6 ) , e l se w h e r e h e a d m i t st ha t "m en w h o have acqu i r ed th i s know l edge ar e thus t he exp e r t s i n hea l ing anddiagnos i s" (p . 170) .

I t is a lso i m por t an t t o r ecogn i ze t ha t i n a l m os t eve r y cu l t u r e t he r e a r e ava r i e t y o f hea l e r s am ong w hom a l ay pe r son can choose . The i nd i v i dua l i n t e r -p r e t a t i ons o f i llnes s t ha t e ach p r ac t i t i one r m ake s a r e su f f i c ien t l y d is t i nc t in m o s tcases t o o f f e r a r ea l cho i ce o f hea l ing t e chn i que . Th i s does no t m er e l y app l y i nt hose s e tt ings w he r e a va r i e t y o f hea li ng tr ad i t i ons i n t e r s ec t , such a s Ta i w an( K l e i nm an 1980) , bu t a lso occu r s in t he u r ban Wes t w he r e m o s t hea l e rs m ayb e a r t h e n a m e " p h y s i c i a n . " T h e c o n c e p t t h a t h e a l in g s ty l es d i f f e r m a r k e d l y e v e nw i t h i n a t i gh t l y c on t r o l l ed , h igh l y p r o f e s s iona l i zed sys t em l i ke B i om ed i c i ne 2 i sa l so no t w e l l a ccep t ed i n t he l i t e r a t u r e , de sp i t e H ehnan ' s ( 1978) and F r e i dson ' s( 197 0) w o r k . P r e ss , f o r exam pl e , s t a te s t h a t in B ogo t a " no t w o cu r e r s a re a l ike . . .each i s a d i s t inc t an d s ty l i s t ic spec ia li s t. I t is easy , in comp ar i son , to v iew thephys i c i an [ sic ] m o no l i t h i ca l l y" ( 1969) . 3 O ne has on l y t o l i s ten t o t he v i o l en ta r gum en t s t ha t occu r , f o r exam pl e , be t w een nephr o l og i s t s and ca r d io l og i st s a st hey d is cuss t he ca r e o f a c r i ti c a l ly il l pe r son t o r ea li z e t ha t such a "m on o l i t h i c "v i ew i s un t enab l e . Th i s occu r s even t hough bo t h a r e cons i de r ed t o be m em ber so f t he s am e spec i a l i ty ( i n t e r na l m ed i c i ne ) .

T h e i m p o r t a n t t h i n g t o n o t e h e r e is th a t a s w e a t t e m p t t o w o r k th r o u g h th ei n t e r ac t i on o f i nd iv i dua l be l i e f sys t em s and ex pe r t be l i e f sys t em s , w e ca nn o ta s sum e t ha t either is a uniform s t r uc t u r e , una f f ec t ed by t he i nd i v i dua l s t hem -selves . I n s t ead w e m us t l o ok a t h ow a pa r t i cu l a r l aym an i n t e r ac t s w i t h a pa r -t i cu l a r expe r t , and f r o m t he se i n t e r ac t i ons d r aw con c l us i ons abo u t t he l a r ge rsys t em .

I N D I V I D U A L B E L I E F S Y S T E M SSickness is a ub iqui to us hu m an exp er ience . By i t s ve ry na tu re , s ickness is ap r o f ou nd t h r ea t t o t he soc ia l and pe r sona l ex i s t ence o f t he i nd i v i dua l. I nd iv i dua lsm u s t t h e r e f o r e ha v e s o m e w a y o f i n t e r p r e ti n g t h e n a t u re o f t h e t h r e a t th a ti llness poses as wel l as avenues wh ich m ay be t ake n to mi t iga te these e f fec t s . In


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A F O L K I L L N E S S W I T H A M E D IC A L N A M E 1 9 9o t he r wo r ds , a be l i e f s ys t em m us t i m bue i ll nes s expe r i ences wi t h m ean i ng andpr ov i de a l te r na t ive cou r s e s o f a c t i on . K l e i nm an has r ecen t l y de s c r ibed a m e t h odt o e l ic i t s uch be l i e fs i n h i s 'Exp l ana t o r y Mode l s o f I ll ne ss ' ( 1980 ) . Th i s m e t hod -o l ogy appea r s t o f unc t i on c r os s cu l t u r a l ly . A ppa r en t l y a ll peop l e need ans wer s t oques t i ons s uch a s "W ha t caus ed t h i s i l lne s s ?" ; "Wh y d i d i t beg i n a t a pa r t i cu l a rt i m e ?" ; "W ha t is happen i ng t o m e? " ; W ha t will be t he ou t co m e o f t h i s i l lne s s ?"a n d " W h a t s h o u l d b e d o n e a b o u t i t? " .

I t i s i m po r t an t t o n o t e t h a t wh i l e we a re p r im ar i l y con ce r ne d w i t h a l aym a n ' sin te rpre ta t io n of h i s i llness a t th i s po in t , exp er t in te rp re ta t io ns of d iseases a ref r equ en t l y o r i en t ed t ow ar ds ans wer ing t he s am e ques t i ons. I ndeed , t he obse r va -t i on t ha t t he cogn i ti ve and p r ac t i c a l d i r ec t i on o f bo t h l ay and e xpe r t illnes se x p l a n a t o r y m o d e l s i n m o s t s o c i a l s y s t e m s c a n b e s u m m e d u p i n t o a s f e wca t ego r i e s a s Kl e i nm an pos t u l a t e s ha s i m m ens e t heo r e t i c a l i m p l i ca t i ons f o r t hec r os s cu l t u r a l s t udy o f s icknes s. Ap pa r en t l y , de s p it e the en o r m ous d i ve r s i ty t ha ti s obse rved in the wa ys tha t i llness i s exp er ien ced and dea l t w i th , there a re ar e l a t i ve l y s m a l l num ber o f co r e f unc t i ons t ha t a r e pe r f o r m ed by nea r l y a l lhea l ing sys tems .

An i nd i v idua l 's ' exp l a na t o r y m ode l ' s hou l d no t be v i ewed a s s om e t h i ng wh i chi s necessar i ly unchan ging . In s tead , i t is a conc i se s t a tm en t o f the indiv idua l ' si ll nes s be l i e f s wh i ch a r e deem ed r e l evan t t o a pa r t i cu l a r a s pec t o f t ha t p e r s on ' sexpe r i enc es a t a pa r t i cu l a r t i m e . As t he a s pec t o f i n t e r e s t i s changed , a s t heexpe r i enc es change , t he e xp l a na t o r y m o de l wi ll change , s om e t i m e s wi t h am az i ngr ap i d i t y . Thus , f o r exam pl e , i f one i nqu i r e s abou t t he phys i ca l c aus e s o f ani ll nes s , an exp l an a t o r y m ode l m ay be g i ven wh i ch w i ll be r ad i ca ll y d i f f e r en t f r omt he e xp l a na t o r y m o de l g i ven by t he s am e i nd i v idua l i f one t hen a sks abou tsp i r i tua l or soc ia l causes o f the same i llness. S ince ex pla na tory mode ls usua l lyc o n t a i n t r e a t m e n t o p t i o n s , t h e p r e s e n c e o f d i ff e r e n t e x p l a n a t o r y m o d e l s f o rd i f f e r en t a s pec t s o f t he s am e i l lne s s m ean s t ha t an i nd iv i dua l m ay b e i nvo l vedi n a va r i e t y o f t r e a t m en t op t i ons , w h i ch t o t he ou t s i de obs e r ve r appea r t o bem u t ua l l y con t r ad i c t o r y , w i t ho u t f ee l ing a cogn i t ive s t ra i n ( Kuns t ad t e r 1976) .Th i s i s r epea t ed l y obs e r ved i n s e tt ings wh e r e t he r e a r e com pe t i ng hea l i ng s ys t em s :i n Ta i wan an i nd i v i dua l m a y us e t he r em ed i e s o f a Wes t er n phys i c i an , a t r ad i-t i ona l C h i nes e do c t o r and a re l ig i ous s ham an a t t he s am e t i m e ( Kl e i nm an 1980) .Ques t i ons a bo u t t he com pa t i b i l i t y o f t he s e tr e a t m en t s a r e u s ua l l y on l y ra i sed byt h e e t h n o g r a p h e r .

Al t hough i t i s i m por t an t t o avo i d r e i f y i ng exp l ana t o r y m ode l s , i t i s a l s oi m p or t an t t o r ecogn i ze t ha t t he s e s eem t o p r ov i de t he j u s t i f i c a t ion f o r t he r ape u t i cac t i on , and t ha t t he r e f o r e , wh i le ephe m er a l , a r e s ti ll a s ubs tan t i ve l ink be t w eent he i nd i v idua l ' s be l i e f s ys t em s and t he ac t i ons t h a t a r e und e r t aken a s a re s u l t o ft he s e be l i e f s ys tem s .W hen w e s peak o f i nd i v i dua l be l i e f s ys t em s , pa r t i cu l a rl y a s t he s e a r e app l i ed


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2 0 0 D A N B L U M H A G E Nt o l a y m e n , t h e r e i s a d a n g e r t h a t w e w i l l b e s e d u c e d b y t h e t e r m " s y s t e m . "S y s t e m a t i c i t y , c o h e r e n c e a n d i n t e r d e p e n d e n c e a r e a s p e c t s o f p ro f e s s i ona l b e l i e fsys t ems . I t i s an unusua l i nd iv idua l ( o r , i ndeed , p r ac t i t i one r ) wh o has wo rkedo u t a ll t h e i n t e r c o n n e c t i o n s o f h i s b e l i e f s y s t e m s o t h a t i t h a s b e c o m e a n i n-t e g r a t e d w h o l e ( B e r g e r a n d L u c k m a n n 1 9 6 7 ) . I t i s m o r e l i k el y t h a t a p e r s o n w il lh a v e a s e t of be l i e f s ab ou t i ll nes s wh ich a r e on ly l oose ly i n t e r con nec t e d , i f a t a ll .T h e c o n n e c t i o n s b e t w e e n t h e i s o l a t e d b e l i e f s m a y b e s u p p l i e d t o m e e t t h e n e e dto exp l a in a pa r t i cu l a r s i t ua t i on . I n add i t i on , i n a pa r t i cu l a r s i t ua t i on , bo th t hei n t e r c o n n e c t i o n s a n d t h e i t e m s o f i n d iv i d u al b e li e fs a p p e a r t o b e c o n t i n u o u s l yr e w o r k e d ( in p a r t t h r o u g h t h e c o n s t r u c t i o n o f a s e ri es o f e x p l a n a t o r y m o d e l s )t o p rov ide a f r amework fo r dea l i ng w i th a pa r t i cu l a r i l l ne s s (AmaraS ingham1980) . I t i s on ly i n t h i s s ense t ha t w e can speak o f an i nd iv idua l il lne s s be l i e fsys t em - i t appea r s i n f ac t to be a s e t o f be l i e fs , a po t e n t i a l s y s t e m w h i c h c a n b eo p e r a t i o n a l i z e d to c o p e w i t h a p a r t ic u l a r e x p e r i e n c e . B e c au s e t i m e a n d e x p e r i e n c ea r e r equ i r ed t o wo rk t he i so l a ted be l ie f s i n to a f unc t i on ing sy s t em, i t m ay no tb e u s e f u l t o q u e s t i o n p e o p l e a b o u t t h e i r e x p l a n a t o r y m o d e l s f o r h y p o t h e t i c a ls i t ua t ions . U n le ss the r e ha s been som e r ea son t o wo rk t h ro ugh t he i r be l ie f s , wh a twi ll be e l i c i ted i n t h a t s e t t ing i s on ly t he f i r s t, mo s t t en t a t i ve , m os t gene ra l iz edshap ing o f t he be l i e f da ta .

Hav ing ou t l i ned t he na tu r e o f t he r e l a t i onsh ip be twe en an i nd iv idua l 's i ll nes sb e l ie f s a n d t h e r e su l ti n g e x p l a n a t o r y m o d e l s , w e n e e d t o e x p l o r e t h e o r i gi n o fi t e m s i n t h e se b e l i e f s y s t e m s a n d e x p l a n a t o r y m o d e l s . T h e r e a r e t h r e e m a j o rsou rce s : i d io sync ra t i c , popu l a r and ex pe r t . Th e f i r s t o f t he se is de r i ved f rom tha tp e r s o n ' s o w n e x p e r i e n c e s, o b s e v a t i o n s a n d r e w o r k i n g o f h is b a si c d a t a u n r e l a t e dto wh a t o the r s s ay o r do . C l ea r l y , t he ex t en t t o wh ich t h i s is a subs t an t i a l sou rceo f a pe r son ' s be l ie f s w i ll va ry f rom pe r so n t o pe r son - t he eccen t r i c w i l l have ag r e a t e r p r o p o r t i o n o f i d i o s y n c ra t i c b e li e fs t h a n a p e r so n w h o t o e s t h e p a r t y l i ne .C u l t u r a ll y , t h e y a r e v e r y i m p o r t a n t s in c e t h e y m a y s e rv e a s a s o u r c e o f n e w i d e a s- c o n c e p t s w h i c h m a y b e a d d e d t o t h e c u l t u ra l d o m a i n o f i ll ne ss b e l ie f s m a k i n gi t m ore adap t i ve , m ore f l ex ib l e , and t he r e fo r e m ore v i ab l e i n a chang ing env i ron -m en t (B uck l ey 1967) . M os t o f t he se i d io sy nc ra t i c be li e f s , o f cou r se , w i ll r ema inu n s t a t e d , o r w i ll b e r e j e c te d t h e i n s t a n t a n i n n o v a t o r h a s t h e t e m e r i t y t o p r o p o s es u c h p r e p o s t e r o u s i d ea s . F r o m a r e s e a r c h s t a n d p o i n t , h o w e v e r , t h e s e id i o s y n c r a ti cbe l i e f s a r e im po r t an t b ecause t hey s e rve a s a sou rce o f va r i ab i l it y i n ou r da t awh ich i s impo ss ib l e t o exp l a in - o r t o i gno re . To u se ano the r j a rgon , t hey a r e" n o i s e " w h i c h m u s t b e c a r e f u ll y e v a l u a t e d b e f o r e e i t h e r in c l u d in g o r r e j e c ti n gt h e m f r o m o u r d a t a b a s e.

A s e c o n d , a n d p r o b a b l y t h e m o s t i m p o r t a n t s o u r c e o f i ll ne ss b e li e fs i s t h e l a yh e a l t h s y s t e m ( C h r i sm a n 1 9 7 7 ) . T h i s i s c o m m o n l y k n o w n u n d e r a v a r i e t y o fn a m e s i n cl u di ng " p o p u l a r h e a l th s y s t e m " a n d m o s t u s e s o f " f o l k h e a l th s y s t e m . "Othe r peop l e ' s i l l ne s se s and i dea s abou t i l l ne s s may be w ide ly d i s cus sed i n


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A F O L K I L L N E S S W I TH A M E D IC A L N A M E 2 0 1or d i na r y conve r s a t i on , wi t h a l t e r na t i ve exp l ana t i ons p r e s en t ed and r e j ec t ed .Th i s i n f o r m a t i on t he r eb y s er ves as a m a j o r r epo s i t o r y o f know l edge wh i ch canbe accu mu la ted in to a se t o f indiv idua l il lness be l i e fs . W hen an i llness occurs , inadd i t i on t o t he i nd i v i dua l r ewor k i ng t he da t a i n h i s own s e t , t he s oc ia l ne t w or kt h a t is a f f e c t e d a r o u n d t h e s ic k p e r s o n b e c o m e s a , i f n o t the , m o s t i m p o r t a n ts ou r ce o f i n f o r m a t i on abou t t he ava i l ab l e i n t e r p r e t a t i ons and p r ac t i c a l a l t e r na -t i ve s . The p r oces s o f nego t i a t i ng m ean i ngs and po t en t i a l a c t i ons am ong t hei d i os ync r a t i c m o de l s o f ill ne ss and t he m o de l s exp r e s s ed by t he s oc ia l ne t w or k isd e a r l y a n e x t r a o r d i n a r il y c o m p l e x p r o ce s s w h i c h h a s b e e n d e s c ri b e d e ls e w h e re( Chr i s m an 1977 ; F r e i ds on 1970) . T he capac i t y o f t he s e f ir s t t wo s ou r ce s o fbe l i e f s and m ode l s i s i l l u s t r a t ed by t he r epea t ed obs e r va t i on t ha t s om ewher ebe t w een 70 and 90% o f all i ll nes s ep i s odes a r e adeq ua t e l y m anaged w i t hou tr equ i ri ng r ecour s e t o ex pe r t know l edge .T h e t h i r d i n p u t t o individual i llness be l i e f sys tems and thu s to the i r explana -t o r y m o d e l s c o m e s f r o m i n f o r m a t i o n d e r iv e d f r o m e x p e r t e x p l a n a t o r y m o d e l s .As t he t e r m is u s ed he r e , " ex pe r t s " a r e no t l i m i t ed t o p r ac t i t ione r s o f the g rea thea l ing t r ad i t ions s uch a s Ay ur ved a o r B i om ed i c i ne bu t m a y be any i nd iv i dua lwho i s s oc i a l l y r ecogn i zed a s hav i ng m or e ex t ens i ve knowl edge o f i l l ne s s andt echn i qu es f o r dea l i ng wi t h i llnes s. As one w ho has b o t h m o r e ex t ens i ve andm o r e s ys t em a t i c kno wl edge o f il lnes s, an exp e r t c an s upp l em en t and o f f e rco r r e c t i on t o i nd i v i dua l exp l ana t o r y m ode l s . ( I n t ak i ng a cogn i t i ve app r oach t oi llness I am s e t t ing as ide th e t echnica l aspec t s of the e xp er t ' s prac t i ce , w hich inm y op i n i on , o f t en p r i m ar i l y s e r ve t o va l i da t e t he i n t e r p r e t i ve a s pec t s . ) Theexp e r t o f f e r s an e xp l ana t o r y m ode l w h i ch ha s wha t eve r p re s t ige t he i nd iv i dua lexp e r t an d h i s hea li ng t r ad i t i on m ay ca r r y ( S t on e 1979) . I t i s i m po r t an t t or em em ber t ha t t he e xpe r t a s we ll a s t he l ay hea l t h s ys t em can on l y o f f e r ex -p l ana t o r y m ode l s - be l i e f s ys t em s can no t be d i r ec t l y t r ans m i t t ed . As s uch thee x p l a n a t o r y m o d e l s c a n t h e n b e a c c e p t e d b y t h e i n di v id u a l as n e w i t em s i n h i ss e t o f i l l ne s s be l i e f s , t o be i n t eg r a t ed wi t h o t he r be l i e f s and expe r i ences andi n c l u d e d o r r e j e c t e d in t h e p r o c e ss o f p r o d u c i n g n e w e x p l a n a t o r y m o d e l s .

C U L T U R A L I L L N E S S B E L I E F S Y S T E M SHav i ng e st ab l is hed t he p r o du c t i on and f unc t i on o f i nd i v idua l be l i e f s ys t em s ,l e t u s t u r n t o wh a t c an be loos e l y t e r m e d t he cu l t u r a l be l i e f s ys t em s . Thes ei nc l ude t he va r i ous popu l a r and t he ex pe r t be l i e f s ys t em s . S i nce I do no t wi s h topos t u l a t e a "g r oup m i nd , " w ha t t he s e cons i s t o f a re t he be l i e f s ys t em s wh i chs eem t o be a neces s a r y ba sis f o r t he exp l ana t o r y m od e l s wh i ch a r e f r equ en t l yexpr e s s ed by t he m em ber s o f a pa r t i cu l a r g r oup . I n t he cas e o f exp e r t be l i e fs ys t em s , t he s e a r e o f t en cod i f i ed i n t ex t bo oks , a l t hough t he cod i f i ed e l em en t st ha t a pa r t i cu l a r expe r t wi ll u s e in t h e ex p l an a t o r y m ode l s he o f f e r s c l ien t s a re


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2 0 2 D A N B L U M H A G E Na l m o s t a s p r o b l e m a t i c a s th e r e l a ti o n s h i p b e t w e e n t h e e l e m e n t s o f th e p o p u l a rb e l i e f s y s t e m a n d t h e e x p l a n a t o r y m o d e l o f a p a r ti c u l a r l a y m a n .

Because o f t he se f ac to r s , p opu l a r i l lne s s be l i e f sy s t em s usua l l y r ema in t a c i tu n t i l t h e i r i m p l i c a t i o n s a re w o r k e d o u t b y e t h n o g r a p h e r s o r u n u s u a l in d i vi d u al sl ik e M u c h o n a , T u m e r ' s ( 1 9 6 7 ) t h e o r e t i c a ll y in c l in e d N d e m b u i n f o r m a n t . T h i sf o l lo w s f r o m t h e n a t u r e o f l a y h e a l t h s y s t e m s , w h i c h c o n s i s t o f t h e b e l ie f s w h i c ha re c o m m o n l y h e l d a n d c o m m u n i c a t e d a m o n g l a y m e n o f a p ar ti c u la r g r o up . A sa l a y m a n b e c o m e s a b le t o a r t i c u la t e t h e p o p u l a r c o n c e p t s o f il ln e ss a s a c o h e r e n ts y s t e m , h e u s u a l ly c e a s es t o b e a m e r e l a y m a n a n d i s r e c o g n i z e d as a n e x p e r t .

Desp i t e t he se cavea t s , l ay sy s t em s do ap pea r t o ex i s t . Ove r l ong pe r i ods o ft ime va r ious so lu t i ons t o i l l ne s s p rob l ems a r e worked ou t and pa s sed on . So lu -t i ons w h ich be t t e r m ee t t he soc i al and p sych o log i ca l needs wh ich a r is e a s t her e su l t o f i ll ne ss r ep l ace t hose wh ich a r e l e ss f unc t i ona l (L in den bau m 1979) . 4A s h a s b e e n p o i n t e d o u t , t h e i n d i v i d u a l i s n o t o b l i g a t e d t o c o m p l y w i t h t h ec u l t u ra l l y a c c e p t e d m o d e s o f i n t e r p r e t i n g a n d h e a l in g s ic k n e ss , b u t a s a n e v e rwiden ing soc i a l ne twork becomes i nvo lved w i th t he s i cknes s , t he r e u sua l l y i si nc r ea s ing p r e s su re t o con fo rm.

T h e v a r io u s h e a l t h b e l i e f s y s t e m s o f a n y p a r t i c u l a r g r o u p a r e o f t e n r e v e al e dby t he wa y t he soc ia l s t r uc tu r e s f o r dea li ng w i th hea l t h a nd i ll nes s ope ra t e .Aga in , de sp i t e a ppa ren t d ive r s i t y , t he r e s eem to be a s e t o f co r e f unc t i on s wh icho p e r a t e c r o s s c u l t u ra l ly . A s K l e i n m a n ( 1 9 8 0 : 7 1 ) h a d o u t l i n e d t h e m , t h e s e a r e :

1. The cultural construction of illness as a psych osocial experience.2. The establishment of general criteria to g uide the health care seeking process and toevaluate treatment approaches that exist prior to and independent o f individual episodes ofsickness.3. The managem ent of particular illness episodes through com mu nicative operations su chas labeling and explaining.4. Healing activities per se, which include all types of therapeutic interventions, fromdrugs and surgery to psycho therapy, suppo rtive care, and healing rituals.5. The ma nag em ent of therapeutic outcom es, including cure , treatment failure , re-currence, chronic illness, imp airment, and deathD u n n ( 1 9 7 6 ) w o u l d a d d t o t h i s l is t:

6. A set o f activities designed to maintain health and redu ce the incidence of illness.The de r i va t i on and imp l i ca t i on o f the se func t i on s ha s been we l l e s t ab l i shed

in t h e me d ica l a n th ro po lo gy l i t e r a tu r e , so t ha t ex t ens ive d is cus s ion he r e is no tw a r r a n t e d . I t s h o u l d b e n o t e d t h a t t h e r e a r e a g a in t w o m a j o r f u n c t io n s w h i c h a r ep e r f o r m e d : a co g n i ti v e fu n c t i o n a n d a n a c t i o n f u n c t i o n . I n o t h e r w o r d s , t w oq u e s ti o n s a r e a n s w e r e d : " W h a t i s h a p p e n i n g t o t h i s p e r s o n ? " ; a n d " W h a t s h o u ldb e d o n e a b o u t i t ? "

O n e o f t h e m o s t i m p o r t a n t a sp e c t s o f t h e c o g n i t iv e f u n c t i o n s o f t h e l a y h e a l t hs y s t e m is t h a t t h e y a r e li n e d t o e v e r y d a y r e a l it y a n d e v e r y d a y o r c o m m o n s e n s e


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A F O L K I L L N E S S W I TH A M E D I C A L N A M E 2 0 3know l edge . T h i s is i n con t r ad i s t i nc t i on t o exp e r t hea l t h s ys t em s wh i ch d r awthe i r cogni t ive l inks to esoteric know l edge s ys tem s . Th i s i s be s t dem ons t r a t ed byG o o d ( 1 9 7 7 ) w h o s h o w s t h a t i n I r a n , d e sp i te p a r t ia l a c c e p t a n c e o f t h e th e o r i e so f t he t h r ee h i gh t r ad i t i ons o f m ed i c i ne ( Ga l en i c- Is l am i c , Sac r ed - Qur ' an i c andBi om ed i c i ne ) , t he l ay o r po pu l a r h ea l t h s ys t em has i ts own v i ew o f c li n ica lr ea l it y w h i ch i s g r oun ded i n t he ex i genci e s and expe r i ences o f eve r yda y l if e . Ass uch t he m ean i ngs a s c r i bed t o i ll nes s te r m s i n pop u l a r he a l t h be l i e f sys t em s a r ed r awn f r om t he de f i n i t i ons o f ev e r yd ay language r a t he r t han p r o f e s s i ona l j a r gon( B e r g er a n d L u c k m a n n 1 9 6 7 ). T o o o f t e n w e t e n d t o l o o k a t t h e e x p e r t d e f i n it i o n- s ince i t i s m os t read i ly avai lab le - and th en assum e tha t l ay m en ( i f the y uset he t e r m a t a l l) u s e the s am e de f i n i t i on . S i nce t he s am e t e r m m ay be g r oun ded i nexp e r t t heo r i e s o f t he caus a t i on o f di seas e on t he one hand , and in com m o ns ens epe r cep t i ons on t he o t he r , we m us t b e cau t i ous t o avo i d th i s dange r .I l lness t e rm s , or l abe l s , func t ion in a var ie ty of way s . In the f i r s t p lace , thel abe l it s e l f i m p l ie s a na r r ow ed r ange o f po t en t i a l exp l ana t o r y m ode l s . Go od ' s( 197 7) de s c r i p t i on o f h ea r t d i st re s s , p r ev i ous l y r e f e r r ed t o , is an exce l l en texam pl e o f t he t yp e o f exp l ana t o r y m ode l s t ha t an i llnes s t e r m can im p l y , andho w t he s e a r e i n t e r con nec t e d . The l abe l t hus s er ves to l i nk a s e t o f be li e fs abo u tthe causes and s igni f icance of par t i cu la r types o f i llness pro blem s wi th a se t ofhea l t h ca r e s eek i ng cho i ce s o f ava ilable t r e a t m en t o p t i ons f o r t he s e t ypes o fi llnes s p r ob l em s (Kl e i nm an 1980 : 108) .

Ho wev e r , becaus e t he p r i m ar y e f f e c t o f an i llnes s is on t he pe r s on and ontha t indiv idua l ' s soc ia l ro le , m an y pop ular il lness t e rm s t end to be l inked wi thpsychologica l and soc ia l impl ica t ions which a re assoc ia ted wi th the i l lness .Thu s t he i llnes s t e r m wi ll t e nd t o l ink wh a t a r e s een a s t yp i ca l s ym pt o m s an dps ycho l og i ca l p r oces s e s wi t h t he t yp i ca l s oc i a l p r ob l em s wh i ch a r e a s s oc i a t edwi t h any pa r t i cu l a r t ype o f i ll nes s p r ob l em ( i b id . ) . Th r o ugh t h i s p r oces s o fde f i n i t i on , bo t h t he behav i o r and t he s oc ia l r o l e o f an i ll pe r s on wi ll be cu l t u r a l l yd i r ec t ed . No t e h ow eve r : t h i s does no t i m p l y t ha t t he behav i o r and s oc ia l r o l ewi ll nece s s a r il y be cu l t u r a l ly de t e r m i ned ; t he r e i s no r m a l l y r oom f o r i nd iv i dua li n t e r p r e t a t io n o f t h e c u l tu r a l p a t t e rn .Thes e a r e t wo p r ob l em s t ha t a ri se f r om t h i s f o r m ul a t i on o f t he s oc ia l con -s t r uc t i on o f i llnes s. The f i rs t o f t he s e conce r ns how p eop l e ac t ua l l y u s e t hep o p u l a r a n d e x p e r t s y s te m o f k n o w l e d g e i n c o n j u n c t i o n w i t h t h e i r o w n id io -s ync r a t i c i n t e r p r e t a t i ons and t he i r pe r s ona l expe r i ences t o gene r a t e exp l ana t o r ym ode l s . I n Go od ' s wo r k , f o r exam pl e , we le a r n t ha t "hea r t d i s ea se" f ir s t is a ss o-c i a t ed wi t h " s adnes s, w or r y , an x i e t y . " I s tha t s i m p l y a s ubcons c i ous f r ee a ss oc ia -t i on on a s oc i e t a l s cal e , o r a r e s peci f ic m echan i s m s pos t u l a t ed wh i ch wo u l di nd i ca t e po t en t i a l i n t e r ven t i ons ? F u r t he r exp l o r a t i on is needed t o c l a r if y t h i s is sue.

The s econd i ss ue i s wh e t he r t h i s s oc i o -ps ycho l og i ca l f r am ew or k ha s an y va lid -i t y i n t he u r ban i zed W est who s e p r i m a r y hea le r s u s e m a t e r i a li s ti c , m echan i s t i c ,


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2 0 4 D A N B L U M H A G E Ns t ochas t ic exp l ana t i ons f o r t he occu r r ence o f d i seas e. Th eor e t i c a l l y we wou l dp r ed i c t a s ever e t ens i on ex i s t i ng be t ween l ay and ex pe r t exp l an a t o r y m ode l s , t ot he po i n t t ha t expe r t i n t e r ven t i on s hou l d be r e j ec t ed a s be i ng i r r e l evan t t o t hef e l t needs o f t he popu l ace . I ndeed , t h is c r it ic i s m is wi de l y l eve led a t the m ed i ca lp r o f e s s i on . Bu t wh a t do t he da t a s how ? W hy do peop l e pe r s is t i n s ee i ng t he i rdoc t o r s ?

S TU D Y D E S IG N A N D M E T H O D O L O G I C A L C O N S I D E R A T I O N ST o address som e of these i ssues , par t i cu la r ly as the y a ri se in a com plex , urb anse t t ing , I des igned a s tud y exp lor ing som e of the i llness be l i e f s o f ma ins t reamA m e r i c a n s . O n e h u n d r e d a n d s e v e n t e e n p e o p l e w h o w e r e o u t p a t i e n t s i n ahyp e r t ens i on c l i n ic we r e i n t e r v i ewed us ing a s em i - s tr uc t u r ed ques t i onna i r e wh i chf o l lo w e d t h e ' E x p l a n a t o r y M o d e l s ' f o r m a t ( K l e i n m a n 1 9 8 0 : 1 0 6 ) . T h e r e s e ar c hw a s c a r d e d o u t o v e r a t w e lv e m o n t h p e r i o d b e gi n n in g S e p t e m b e r 1 9 7 7 .

The r e a r e a num ber o f m e t hodo l og i ca l is sues w h i ch a f f ec t t he gene r a l iz ab i li t yo f the resul ts and m us t b e d i scussed. Since I was pr im ar i ly in te res te d in il lnessbe l i e f s i n an u r ban s e t t i ng , t r ad i t i ona l an t h r opo l og i ca l t e chn i ques t o i den t i f y as t udy pop u l a t i on ( t he i s o l a ted v i llage ) cou l d no t be u s ed . Popu l a t i on s am pl i ngwas be yo nd ou r f 'mancia l and t ime cons t ra in t s . As a resu l t , I e l ec te d to s tud ya popu l a t i on wh i ch was de f i ned biomedically and administratively. Thes ewer e i nd i v i dua l s who wer e a t t end i ng a pa r t i cu l a r c l i n i c a t t he Sea t t l e Ve t e r ansAd m i n i s t r a t i on M ed ica l Cen t e r . T he on l y o t he r fo r m a l c r i t e r ion was tha t t he yhad been a t t end i ng t he c l i n i c f o r a t l e a s t s i x m on t hs . Th i s t i m e r e s t r i c t i on wass e t t o a l low t he pa t i en t ' s i l lne s s be l ie f s t o com e i n t o equ i l i b r ium wi t h a newc l in i c env i r onm en t .

T h e s e r e s t ri c ti o n s w o u l d b e e x p e c t e d t o h a v e a n u m b e r o f e f f e c t s o n t h e d a t a .Se l ec ti ng peop l e wh o h ave e l ec t ed t o s eek and r em a i n i n m ed i ca l c a r e wi ll se l ec tt hos e whos e exp l ana t o r y m o de l s a r e l es s li ke l y t o be i n con f l i c t wi t h t he p r o -f e s s i ona l ' s m ode l . I n o t he r wor ds , any popu l a r hea l t h be l i e f s f ound i n t h i spop u l a t i on wo u l d s ugges t t ha t t he s e be l ie f s a r e m uch m or e w i de l y he l d am ongt he p opu l a t i on a t l ar ge.

Adm i n i s tr a t ive l y , on l y t hos e i nd iv i dual s who have s e r ved i n t he Un i t ed S t a t e sAr m ed For ce s a r e e lig ib le f o r hea l t h ca r e t h r oug h t he V e t e r ans Ad m i n i s t r a t ion .Th i s r e su l ts in a p r epon de r an ce o f m a l es : t hus , o n l y 2 o f t he 103 i nd iv i dual sf i na ll y i nc l uded i n t he s t udy we r e w om en . I c ann o t p r ed i c t t he e f f ec t o f t h i ss kewed s ex r a t i o o n t he da t a . I n add i t i on , m i no r i t y g r oups we r e und e r r ep r e s en t ed .Of t he 103 , 90 we r e wh i t e ( i nc l ud i ng bo t h wom en) , 9 we r e b l ack , 2 Am er i canI nd i an and 2 F i l ip i no . T he e f f ec t s o f m i no r i t y g r oup m ode l s o f i ll nes s wi ll bed i scus sed l a t e r i n t he pape r . S i nce t he p r i m a r y i n te r e s t is i n t he hea l t h be l i ef s o fmains t ream Amer icans , th i s sample se rves our purposes .


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A F O L K I L L N E S S W I T H A M E D I C A L N A M E 2 0 5O t h e r s o c i o d e m o g r a p h i c c h a r a c t e ri s ti c s o f th i s g r o u p a r e a s fo l lo w s : m e a n a g e

w a s 5 5 . 4 y e a r s w i t h a r a n g e o f 2 2 t o 7 9 . M e a n e d u c a t i o n a l a c h i e v e m e n t w a s 1 1 . 9y e a r s , w i t h a r a ng e f r o m 3 y e a r s t o a P h . D . c a n d i d a t e . M e a n o c c u p a t i o n a l s t a t u sm e a s u r e d b y t h e s e v en p o i n t H o l l in g s h e a d s c al e w a s 4 .5 5 w i t h a r an g e o f 1(h ighes t ) t o 7 (Bon jean e t a l . 1967 ) . To summar i ze t he se da t a , t he popu l a t i onc o n s i st e d o f p r e d o m i n a n t l y w h i t e m i d d l e a g e d m e n w i t h a h i g h s c h o o l e d u c a t i o nw h o w e r e e m p l o y e d i n a m i d d l e c l a ss o c c u p a t i o n .

The r ea son fo r s e l ec t i ng a pa r t i cu l a r c l i n i c was t o ensu re t ha t a l l i nd iv idua l shad a s imi l a r phys io log i ca l expe r i ence , and t ha t t hey we re a l l g iven t he s amep r o f e s si o n a l e x p l a n a t o r y m o d e l . H y p e r t e n s i o n w a s s e l ec t e d a s t h e i n d e x m e d i c a lcond i t i on pa r t l y f o r admin i s t r a t i ve r ea sons : i . e . , t he r e was a c l i n i c i n ope ra t i onw h o s e s t a f f w a s a m e n a b l e t o o u r r e s ea r c h . H o w e v e r , a s e c o n d i m p o r t a n t r e a s o ni s t h a t u n c o m p l i c a t e d h y p e r t e n s i o n c a n e x i s t a s a c h r o n i c c o n d i t i o n w i t h o u ts i g ni fi c an t n u m b e r s o f o t h e r c o e x i s ti n g m e d i c a l p r o b l e m s . T h is i s n o t a s t r u e f o rhea r t d i s ease , d iabe t e s , o r ch ron i c l ung d i s ease , f o r exam ple . I nd iv idua l hea l t hbe l i e f s a r e no t nea t l y s eg rega t ed i n to d i sea se spec i f ic packages , and w e f e l t t ha to u r t a s k w o u l d b e m u c h s i m p l e r i f w e c o u l d l i m i t t h e d i sc u s si o n t o t h e e x p e r i e n c eo f a s ingle i l lness.

A 2 2 i t e m s e m i - s t r u c t u r e d q u e s ti o n n a i r e b a s e d o n K l e i n m a n ' s E x p l a n a t o r yM o d e l s q u e s t i o n s ( 1 9 8 0 : 1 0 6 ) w a s d e v e l o p e d a n d p r e t e s t e d o n s i x i n d iv i d ua l sw h o w e r e n o t p a r t o f t h e s t u d y . T h e r e s u lt in g re v is e d q u e s t i o n n a ir e w a s t h e ng i ve n t o 1 1 7 p a t i e n t s i n t h e c l in i c b y t h e c h i e f i n v e s t ig a t o r , w h o w a s in t r o d u c e da s a g r a d u a t e s t u d e n t i n a n t h r o p o l o g y a n d t h e r e f o r e s o m e o n e w h o w a s a d m i n i s-t r a t i ve ly un re l a t e d t o t he c l i n ic . The i n t e rv i ews l a s t ed t en t o t h i r t y minu t e s . A lli n t er v i e w s w e r e t a p e r e c o r d e d a n d t r a n sc r ib e d . F o u r t e e n o f t h e r e c o rd i n g s w e r et echn i ca l l y i nadeq ua t e f o r t r ansc r i p t i on (u sua l l y due t o e lec t r i c a l i n t e r f e r enc e )a n d w e r e e l i m i n a t e d , h a v i n g 1 0 3 p e o p l e i n t h e s t u d y . A l l d a t a h e r e s t e m f r o mthese 103 in te rv iews .

R E S U L T SE a c h i n t e r v i e w w a s a n a l y z e d t o d e t e r m i n e t h e i n d i v i d u a l ' s e x p l a n a t o r y m o d e l o fh y p e r t e n s i o n . U s i n g t h e p e r s o n ' s o w n w o r d s a s m u c h a s p o s s i b l e , t h e m o d e l sw e r e d i a g r a m m e d in t o a s e t o f ' n o d e s ' a n d ' a r r o w s ' w h e r e t h e n o d e s a r e i m -p o r t a n t f a c to r s in e x p l a n a t io n s o f e ti o lo g y , p a th o p h y s i o l o g y a n d o u t c o m e , a n dt h e ' a r r o w s ' r e p r e s e n t t h e c a u s al r e l at i o n sh i p s w h i c h w e r e s a i d t o e x i st b e t w e e nt h e n o d e s ( F i g u r e 1 ). T h e i n d i v id u a l m o d e l s c o n t a i n e d a m e a n o f t h i r t e e n n o d e sw i t h a r a n g e o f f o u r t o t w e n t y - s i x . I t c a n b e s e e n f r o m t h e e x a m p l e t h a t w ea r e d e a l in g w i t h r e l a t iv e l y c o m p l e x m o d e l s . A s w o u l d b e e x p e c t e d , t h e m o d e l swere no t nece s sa r i l y i n t e rna l l y cons i s t en t . On occ as ion i nd iv idua l s gave two o rm o r e p a r a l l e l , n o n i n t e g r a t e d m o d e l s a t d i f f e r e n t p o i n t s i n t h e i n t e r v i e w . W h e n


10/31

2 0 6 D A N B L U M H A G E NN E R V O U SB R E A K D O W N

" X ~ T E N S I O NUPSET

F A T T Y ~ " / ' fFOODS" ~ H A R D TODIGEST

SMOKING CONSTRICTSBLOOD - -VESSELS

FAMILY DIZZ Y SPELLSARGUMENTS FLASHtNG LIGHTS HEAVINESSIN CNESTINCREASED H IG H / FLUSHEDCIRCULATION - - PRESSURE

DISABILITYBALLOONING =BURDEN ON. . . . . OR ~ V E I i S O T/E RSBLOOD TO STROKENLARGEDCIRCULATE IN HEART RUPTUREDS T O . . . ~ S L O O OHEART VESSELBLO OD S TA YS A TTAC K ~ _IN STOMACH =HEART ~ LOSE ALON iER BURSTING KIDN EYSLOWER /CIRCULATION SALT ~ STRAIN ON

KIDNEYSFIGURE 1 AN INDIV IDUA LMOD EL OF HYPERTENSION

i n c o n s i s t e n c ie s w e r e p o i n t e d o u t , a t y p i c a l r e sp o n s e w a s : " 1 n e v e r t h o u g h t o f i tt h a t w a y , " s u g g e s t i n g t h a t t h e i n c o n s i s t e n c i e s w e r e n o t p r o b l e m a t i c t o t h ep e r s o n i n t e r v i e w e d . T h e m o d e l s a l s o h a d p o i n t s o f m e r g e r , w h e r e se v er a l s t r a n d sj o i n t e d i n a s in g le o u t c o m e , a n d a l s o h a d b r a n c h i n g s , w h e r e a s in g l e f a c t o r c o u l dr e su l t in a v a r i e ty o f o u t c o m e s .

A m a n u a l s o r t i n g a n d g r o u p i n g t e c h n i q u e w a s d e v i s e d w h e r e b y n o d e s w h i c hw e r e i n s t r u c t u r a l l y s i m i l a r l o c a t i o n s i n t h e v a r i o u s i n d i v i d u a l s ' m o d e l s a n dw h i c h h a d s im i la r s e m a n t i c c o n t e n t w e r e g r o u p e d f o r t h e e n t ir e s a m p l e o f 1 0 3i n d i v i d u a l e x p l a n a t o r y m o d e l s . T h i s t e c h n i q u e a l l o w e d t h e 1 3 0 0 i n d i v i d u a ln o d e s t o b e c o l la p s e d i n t o a s e t o f 5 9 c a t e g o r ie s . T h e c a te g o r ie s w h i c h o c c u r r e di n m o r e t h a n 2 0% o f t h e i n d iv i d u a l m o d e l s w e r e s e l e c te d a s b e i n g i n d i ca t iv e o f ap o r t i o n o f a c u l t u r a l m o d e l . T h e s e w e r e c o m b i n e d w i t h t h e i r f ir st o r d e r a r r o w st o g i v e a s u m m a r y d i a g r a m w h i c h I c a l l t h e C o g n i t i v e D o m a i n o f H y p e r t e n s i o n( F i g u r e 2 ) . I n t h i s f ig u r e th e w i d t h o f t h e a r r o w s a n d t h e s i z e o f e a c h n o d e a rep r o p o r t i o n a l t o t h e n u m b e r o f p e o p l e w h o g a v e t h a t i t e m i n t h e i r i n d i v i d u a lm o d e l s . T h e n o d e s i n t h e c o g n i t iv e d o m a i n m o d e l c a n b e fu r t h e r c la s s if ie d a sc a u se s , in t e rm e d i a te m e c h a n i sm s a n d o u t c o m e s o f h y p e r t e n s i o n . T h e n u m b e r o fp e o p l e w h o i n c l u d e d a p a r t ic u la r n o d e i n t h e i r i n d iv i d u a l m o d e l s i s s h o w n inT a b l e s 1 - 3 . T h e n o d e s o f t h e s u m m a r y dia gr am a c c o u n t fo r 90 % o f a l l t h en o d e s g iv e n i n t h e in d i v i d u a l m o d e l s . H o w e v e r , 5 6% o f t h e p e o p l e i n t e r v ie w e dh a d a t l e a s t o n e c o n c e p t w h i c h i s n o t p r e s e n t e d h e r e , s o t h a t o n l y 4 4 % o f t h ei n d i v id u a l m o d e l s c a n b e e n t i r e l y m a p p e d o n t o t h e n o d e s o f t h e c o g n i t i v ed o m a i n .

T h e a r ro w s l in k i n g t h e n o d e s a r e m o r e d i f f i c u l t t o i n t e r p r e t . T o b e i n c l u d e dt h e y h a d t o b e g i v e n b y a t l e a st 5% o f t h e s a m p l e , a n d t h e l ar g es t w a s o n l yi n c l u d e d b y 3 9% . D u r i n g th e i n t e r v ie w s I g a in e d t h e i m p r e s s i o n t h a t w h e r e as t h e


11/31

A F O L K I L L N E S S W I T H A M E D I C A L N A M E 2 0 7

FIGURE 2 THE COGNITIVE DOMABN OF HYPERTENSION

c o n c e p t s e x p r e s s e d h e r e a s n o d e s a r e f a i r ly s t a b l e e l e m e n t s o f t h e i n d i v i d u a l ' sb e l i e f s y s t e m , t h e l i n ks d r a w n b e t w e e n t h e m a re n o t , a n d w e r e a m e n a b l e t ob e i n g s h i f t e d a r o u n d i n r e s p o n s e t o a d i f f e r e n t l in e o f q u e s t io n i n g . T h e o r e t i c a l l y ,t h i s i s w h a t w e w o u l d e x p e c t . N o n e t h e l e s s , t h e w i d e r a n g e o f i n d i v i d u a l v a r i a t i o nc o u p l e d w i t h t h e i n h e r e n t a m b i g u i t i e s o f t h e s e li n k s m a k e i t i m p o s s i b l e toe s t i m a t e t h e " c o m p l e t e n e s s " o f t h is a s p e c t o f t h e c o g n i ti v e d o m a i n .

TABLE 1Causes

N %A cut e Stress 57 56Chronic Externa l S t ress 50 49Ch ronic Inter nal Stress 14 14Smo king 15 15Alcoh ol 16 16Personal i ty Trai t 17 17Here di ty 25 25Foo d 33 32Salt 56 55W ater 43 42


12/31

2 0 8 D A N B L U M H A G E N

TABLE 2Interm ediate M echanismN %

Hy per tension 63 62Vessels Co nstr ic t 12 12Hear t Beats Faster 23 23Hear t Works Harder 34 33Altered Circulat ion 31 30Narrowed Blood Vessels 43 42Circulat ion Cut Off 16 16Overweight 48 47High Pressure 48 47Hea rt Strain 33 32Burst Bloo d Vessel 29 28

TABLE 3O u t c o m eN %

Tiredness 18 18Dizziness 28 27Headache 21 21Flushing 31 30Em ot iona l Sym ptoms 29 28Stroke 68 67Physical Damage 29 28Hear t A t t ack 46 45Hear t Fai lure 33 32Paralysis 17 17Death 26 25

C O N T E N T O F T H E N O D E S

H a v i n g d e s c r i b e d t h e o r i g in o f t h e d i a g r a m , i t is v e r y i m p o r t a n t t o p r e s e n t t h ec o n t e n t s o f s o m e o f t h e n o d e s . T h e r e m a i n d e r a re e it h e r s e l f -e x p l a n a t o r y a n dh a v e v e r y l i t t l e i n t e r n a l v a r i a t i o n , o r a r e r e l a t iv e l y u n i m p o r t a n t t o t h e o v e r a lls c h e m a ; t h e r e f o r e n e i t h e r w i ll b e e x t e n s i v e l y d is c u s s e d .

T h e r e a r e t w o m a j o r s e t s o f c a u s e s o f t h is il ln e s s . T h e s e a r e ro u g h l y d i v i d e di n t o p s y c h o - s o c i a l c a u s e s o n t h e l e f t o f t h e d i a g r a m , w h i c h r e s u l t i n a s t a t e c a l le dH y p e r - T e n s i o n , a n d a s e t o f p h y s i c a l - h e r e d i ta r y f a c t o rs s h o w n a t t h e b o t t o mw h i c h a f f ec t t h e p r e ss u re i n t h e b o d y . M a n y o f t h e p e o p l e i n t e r v i e w e d g a ve b o t hs y s t e m s . F o r c l a r i t y i n t h e p r e s e n t a t i o n , t h e t w o m a j o r s y s t e m s w i ll b e d i s c u s s e ds e p a r a t e l y .


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A F O L K I L L N E S S W I T H A M E D I C A L N A M E 2 0 9P S Y C H O - S O C I A L C A U S E S A N D M E C H A N I S M S

T h e m o s t i m p o r t a n t o f t h e p s y c h o - s o c ia l c au s es o f t h e il ln es s ' H y p e r . T e n s i o n 'f al l i n t o a c a t e g o r y c a l le d " C h r o n i c E x t e r n a l S t r e s s . " N e a r l y h a l f o f t h e p e o p l ei n t e r v ie w e d s a id t h a t t h is w a s a s ig n i f ic a n t f a c t o r i n t h e p r o d u c t i o n o f th e i r ill-n e ss . A s c a n b e s e e n f r o m T a b l e 4 th i s c a t e g o r y w a s u s e d t o g r o u p t h r e e t y p e s o fs o c i a l a n d e n v i r o n m e n ta l s t r es s e s: F i r s t w a s a s in g l e e p i s o d e o f e x t r e m e s t r e s s, s u c ha s b e i n g a t P ea r l H a r b o r d u r i n g t h e J a p a n e s e r a id i n 1 9 4 1 , o r i n th e 1 9 6 4 A l a s k a n

TABLE 4Chronic External StressN = 50, 49% of TotalCategoryN %

I. Single Episode of Extreme Stress 5 10II. Job StressesWork Too Hard 7 14Specific Occup ation 5 10Job Stress 13 26Unem ployment 2 4III . Buildup of Normal StressesLife's Stress and Strain 9 18Tension 11 22Worry/Anxiety/Nervousness 9 18Pressure 4 8Insufficient Rest 4 8

Totals are greater tha n 1 00% because som e respondents listed multiple items.

e a r t h q u a k e . S e c o n d l y , t h e r e w e r e a se t o f s t re s s o rs r e l a t e d t o e m p l o y m e n t : Ap a r t i c u l a r l y d e m a n d i n g o c c u p a t i o n , s u c h a s b e i n g a s u b m a r i n e r . D i s a g r e ea b l ec o l l ea g u e s o r j u s t t o o m u c h h a r d w o r k , p o s s i b l y a s a m a n u a l l a b o r e r , w e r e a l s oc o n s i d e r e d t o b e s i g n i f i c an t c a u s e s . F i n a l l y , a n a c c u m u l a t i o n o f s t re s s o f n o r m a ll iv i ng is a l s o o f t e n g i v en a s a r e a s o n f o r d e v e l o p i n g h y p e r t e n s i o n . T h e i m p o r t a n td i f f e r e n c e b e t w e e n t h is c a t e g o r y a n d t h e n e x t , w h i c h I c a ll c h r o n i c i n t e r n a ls t re s s , i s t h a t h e r e t h e s t r e s s o r s s e e m to o r i g in a t e o u t s i d e t h e i n d iv id u a l a n d h i si m m e d i a t e f a m i l y n e t w o r k . F o r a v a r i et y o f re a s o ns t h e t w o c a t eg o r ie s s e e m e dt o s e g r e g a t e d i f f e r e n t l y a n d t h e r e f o r e a r e k e p t a p a r t i n t h e d i a g r a m .

C h r o n i c i n t e r n a l s t re s s ( T a b le 5 ) re l a t es t o e i t h e r p s y c h i a t r i c p r o b l e m s - s u c ha s c h r o n i c s c h i z o p h r e n i a - o r l o n g - s t a n d i n g i n t r a f a m i l ia l p r o b l e m s . A n a s t ym o t h e r - i n - la w o r a n u n f o r t u n a t e m a r r ia g e w i t h a m e s s y d i v o rc e ar e e x a m p l e s o ft h is . I n t e r e s t i n g l y t h i s d i f f e r e d f r o m t h e c a t e g o r y l a b e l e d ' P e r s o n a l i t y T r a i t 'w h i c h i s a n e x p r e s s i o n o f t h e i d e a " I ' v e a l w a y s b e e n a h i g h t e n s i o n p e r s o n . "


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TABLE 5Chron ic In ternal S t ressN = 14, 14% of To tal

Ca tegoryN %Psychological Prob lem s 7 50Fam i ly o r I n t e rpe r sona l P rob lems 9 64Totals are greater than 100% because some responde nts l i s ted mul t ip le i tems.

D e s p i t e t h e f a c t t h a t t h is i s a n in n a t e c h a r a c t e r i s t i c o f t h e i n d i v i d u a l , i t is n o ts e e n a s i n h e r i t e d , i . e. , d e r i v e d f r o m a p a r e n t a l t r a i t. P e o p l e a c t u a l l y sa i d " I ' v ea l w a y s b e e n a t e n s e p e r s o n a n d m y m o t h e r w a s t o o , b u t I d o n ' t t h i n k i t w a si n h e r i t e d . "

A c u t e S t r e s s ( T a b l e 6 ) i s a n y s i t u a t i o n w h i c h i s s e e n a s t e m p o r a r i l y a ff e c t i n gt h e i n d i v i d u a l. E x a m p l e s o f t h is w e r e b e c o m i n g a n g r y w i t h s o m e o n e , b e i n gs t o p p e d b y a p o l i c e m a n , o r h a v i n g s e x . P e o p l e v i e w e d th e m s e l v e s a s h a v i n g b e e nm a d e m o r e v u l n e r a b l e t o b e c o m i n g ' h y p e r - t e n s e ' i n s u ch s i t u a t i o n s . A lo n g s e ri e so f s u c h c i r c u m s t a n c e s c o u l d r e s u l t i n a n a l te r e d p h y s i c a l s ta t e , b u t w o u l d t h e nb e c l a s s i fi e d u n d e r " C h r o n i c E x t e r n a l S t r e s s . "

TABLE 6Acu te S t r essN = 57 , 56% of To ta lCategoryN %

I . Phys ical Overexer tion 8 14II . In ternal S t ressW orry /Anx ie ty 12 21Nervous 7 12Emo t ions 5 9Anger 5 9III . Soc ial S t ressStressful Situ ation 27 47Exc i temen t 11 19Social Demands 6 11

Totals are greater than 100% because some responde nts l i s ted mul t ip le i tems.

T H E M E A N I N G O F H Y P E R - T E N S IO N

A l l o f t h e s e c a u s a l f a c t o r s r e s u l t e d i n a s t a te I c a l l ' H y p e r - T e n s i o n ' . T h i s m u s t b ed i s t in g u i s h e d fr o m t h e b i o m e d i c a l d e f m i t i o n o f h y p e r t e n s i o n , w h i c h r e fe r s t o a


15/31

A F O L K I L L N E S S W I T H A M E D I C A L N A M E 2 11s u s t ai n e d e l e v a t io n o f t h e h e m o d y n a m i c p r e s s u r e i n th e s y s t e m i c c ir c u l a t io no f t h e b o d y . S i n c e l a y t e r m i n o l o g y i s r e l a te d t o e v e r y d a y E n g li sh i n s t e a d o fp r o f e s s i o n a l j a r g o n t h e n a t u r a l t r a n s la t i o n o f t h i s t e r m w o u l d b e " e x c e s si v et e n s e n e s s . " T h i s is w h a t w a s f o u n d w h e n p e o p l e w e r e a s k e d t o d e s c ri b e w h a t t h e ym e a n t b y ' H y p e r - T e n s i o n ' . T a b le 7 g i ve s t h e d e s c r ip t iv e te r m s t h a t w e r e u s e d.Whi le m an y o f t he se occu r r ed t oo r a r e ly to be s t a t i s ti c a l l y s ign i f ic an t , wh en t h eya re pu t t oge the r t h ey pa in t a g r aph i c p i c tu r e o f t h i s i ll ne ss . The re a r e , how eve r ,t w o c o m p o n e n t s t o ' H y p e r - T e n s i o n ' . I n t h e f i rs t p l ac e i t i s a st a te c h a r a c t e ri z e db y t h e e x p e r i e n c e o f n e r v o u s n e s s, f e a r , a n x i e t y , w o r r y , a n g e r , u p s e t , t e n s e n e s s,o v e r a c t i v i t y , e x h a u s t i o n a n d / o r e x c i t e m e n t . S e c o n d l y i t i s a c o n d i t i o n b r o u g h to n b y t h e p s y c h o s o c i a l f a c t o r s a lr e a d y d i sc u ss e d w h i c h m a k e s t h e i n d i v id u a lm o r e s u s c e p t i b l e t o b e c o m i n g ' h y p e r - t e n s e . '

TABLE 7Hyper-Tension: D escriptive TermsN

Nervousness 15Irritated Nerves 2Tenseness 4Fear/Anxiety/Worry 6Overactive 4Anger/Upset 5Exhaustion 3Frustrated 1Mind Working 1Emotional 1Deterioration 1Grinding Teeth 1Impatience 1High Stress 1Excited 2Being up Tight 1High strung 1Shook Up 1

D e s p i t e t h e p s y c h o l o g i c a l s o u n d o f t h e e x p e r i en c e s a ss o c i a te d w i t h ' H y p e r -Ten s ion ' , i t i s cons ide r ed t o be a phys i ca l and spec i fi c a l ly no t a p sycho log i ca ld i so rde r . I t i s no t an i ll ne ss w h ic h i s "a l l i n a pe r s on ' s he ad , " bu t app ea r s t oinvo lve a phys i ca l change i n t he pe r son , a l t ho ugh t he na tu r e o f t h i s change i s no tspec i f i ed . Thus , f o r example , de sp i t e t he f ac t t ha t t en senes s i s a c en t r a l pa r t o fthe i l lness , t ranqui l izers a re n o t c o n s i d e r e d t o b e a p p r o p r i a t e t h e r a p y .

T h e s t a t e o f ' H y p e r - T e n s i o n ' m a n i f e s t s i t s e x is t e n c e in v a r io u s w a y s . T h ep r i m a r y a c t i o n i s o n t h e h e a r t , w h i c h m a y p u m p f a s t e r o r h a r d e r r e s u lt in g in a n


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i n c r e a se i n p r e s s u re b o t h o n t h e b l o o d ( h i g h b l o o d p re s s u r e ) a n d o n t h e b o d y a sa w h o l e . M a n y i n f o r m a n t s e x p l i c it l y m a d e t h i s d i s t in c t i o n b e t w e e n ' H y p e r -T e n s i o n ' a n d h i g h b l o o d p r e s s u r e . A s o n e p e r s o n s a i d :My interpre ta t ion is tha t the H yper-Tension moves in to h igh blood pressure and causeshigh b lood pressure . I th ink that ' s where i t real ly gets i t s mo me ntum f rom , to cause theblo od pressure to go up.[Hyper-Tension] is nervousness, a con dition , a pr e ss u re . . . I have a fast moving pressurething. Like on a t readm il l , moving al l the t im e, fast , I th ink . . . and then there 's somenervousness a bou t i t , som e nervousness, some wo rry and conce ntrat ion that the load is tooheavy for the mind to car ry i t . . . i t over loads someplace, causes a shor t c i rcuit .I d idn ' t kno w i t was high blood pressure. [Note the sh i f t in terms.] I got shor tness o fbreath . I 'd walk up a sho r t ramp and I was out o f breath . Went to the do ctor for somethingelse . . . and he discovered th at my blood pressure was way up . . . . [The doc tor said]' s tabi l ize you r b od y, you had i t s tabi l ized and i t should s tay the re . ' I t ' s just l ike a spr ingi f you had i t down now i f you r el ease i t [ by no t t ak ing med ica t ion ] i t ' l l go back up anddamage your hear t .T h i s d i s t i n c t i o n h a s n o c o r r e l a te w i t h i n t h e p r o f e s s i o n a l d e f i n i t i o n s o f tb .zd i s e a s e .

H E R E D I T A R Y - P H Y S I C A L C A U S E S O F H I G H B L O O D P R E S S U R E

I n a d d i t i o n t o t h e p e o p l e w h o b e l i e v e d t h a t s t re s s c a u s e d th e i r H y p e r - T e n s i o nt h e r e w e r e a s u b s t a n t ia l n u m b e r i n th i s s t u d y w h o f e l t t h a t t h e i r il ln e s s w a sc a u s e d b y p h y s i c a l o r h e r e d i t a r y f a c t o r s , a n d n o t p s y c h o s o c i a l o n e s. H e r e t h ep r i m a r y m o d e l w a s t h a t a v a r ie t y o f f a c t o r s c a u s e d a n a r r o w i n g o n t h e b l o o dv e ss e ls . T h i s c o u l d b e d u e t o h e r e d i t a r y f a c t o r s , s a l t w h i c h w o u l d c a u s e d e p o s i t si n t h e b l o o d v e s se ls o r e x c e ss i ve w e i g h t s q u e e z i n g t h e b l o o d v e s se ls . W h a t e v e rt h e c a u s e , t h i s a l te r a t i o n in b l o o d f l o w w a s s ee n a s m a k i n g t h e h e a r t w o r k h a r d e ra n d t h e r e b y i n c r e a s in g t h e b l o o d p r e s s u r e .

S i m i l a r l y , t o o m u c h f o o d w a s s e e n as c a u s i n g a p e r s o n t o b e c o m e o v e r w e i g h t ,w h i c h w o u l d t h e n s tr es s t h e w h o l e b o d y s y s t em . T h i s w o u l d o c c u r e i th e r b yn a r r o w i n g t h e b l o o d v e s se l s a s h a s b e e n d e s c r i b e d , b y p u t t i n g a n a d d i t i o n a lw o r k l o a d o n t h e h e a r t , o r s i m p l y b y i n c re a s in g th e b o d y ' s ' p r e s s u re . ' F a t t y f o o d sa n d s a l t w e r e f e l t t o b e p a r t i c u l a r l y d a n g e r o u s i n t h i s r e g a r d . S a l t r e p o r t e d l yh o l d s o n t o w a t e r , w h i c h e i t h e r m a k e s o n e o v e r w e i g h t , o r s i m p l y in c r e a s e s t h ef l u i d p re s s u r e i n t h e ' s y s t e m . ' T h e c o n c e p t o f 'w a t e r ' c o n t r i b u t i n g t o o v e r w e i g h ta p p e a r s t o b e w i d e s p r e a d , a n d p r o b a b l y i s d u e t o t h e w e l l -k n o w n p h e n o m e n o ,o f p r e m e n s t r u a l w e i g h t g a i n a n d t o t h e s i m i l a r ly w e l l - k n o w n e f f e c t o f w a t e rr e t e n t i o n d u r i n g w e i g h t l o ss . S i n c e h y p e r t e n s i o n i s u n i v e r s a ll y t r e a t e d w i t hd i u r e t i c s ( ' w a t e r p i l l s ') w h i c h a r e a l s o p o p u l a r l y u s e d f o r p r e m e n s t r u a l e d e m aa n d w e i g h t l o s s , t h i s p r o f e s s i o n a l p r a c t i c e s u p p o r t s a p o p u l a r c o g n i t i v e s y s t e mu n r e l a t e d t o t h e p r o f e s s i o n a l c o g n it i v e s y s t e m .


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A F O L K I L L N E S S W I T H A M E D IC A L N A M E 2 1 3T H E E F F E C T O F H I G H P R E S S U R E

A s F i gu r e 2 i nd i ca t e s , m os t o f t he e f f ec t s o f t h i s il lnes s w o r k t h r oug h t he i n t e r -m ed i a t e m echan i sm o f h i gh p r e s su r e . Ju s t a s the r e a r e p sychosoc i a l a s w e l l a sphys ica l causes of h igh pressure , the re a re psyc hoso c ia l and phys ica l resu l ts .The psychosoc i a l e f f ec t s a re show n a t t he t op o f t he d i ag ram and cons is t o f t heca t ego r i e s t i r ednes s , d i zz i ne s s , headache , f l u sh i ng and em ot i ona l sym pt om s .Mos t o f t he se ca t ego r i e s a r e s e l f - exp l ana t o r y . I t m us t be no t ed t ha t de sp i t ei n tens i ve c l in i ca l r e sea rch , no cons i s t en t c o r r e l a t i on can be e s t ab li shed be t w eent he b l ood p r e s su r e a s m easu r ed by a phys i c i an us i ng a sphygm om anom e t e r( b l oo d p r e s su r e cu f f ) and t he se sym pt om s ( K ap l an 1978) . Th is i nc ludes head -a ch es. T h e s e s y m p t o m s m u s t t h e r e f o r e b e c o n s i d e r e d to b e s y m p t o m s o f apop u l a r o r f o l k i llnes s and no t pa r t o f t he pa t hop hys i o l ogy o f ( p r o f e s s i ona l l yde f i ned ) h igh b l o od p r e s su re .

The on l y one o f t he se sym p t om s w h i ch r equ i re s f u r t he r d is cuss i on he r e is t heca t ego r y o f ' em o t i ona l sym pt om s . ' T ab l e 8 lis ts t he se . These inc l ude a l t e r edin te rna l , psych ologica l s t a tes as wel l as a ch anged soc ia l s t a tus . I f th i s tab le i scom par ed w i t h t he t ab l e s de sc r ib i ng A c u t e S t r es s and H ype r - Tens i o n ( Tab l e s6 and 7 ) i t i s i m m e d i a t e l y obv i ous t ha t m any o f t he f ac t o r s w h i ch a r e sa id t ocause H y per - Tens i on a r e a lso s een a s t he result o f H y p e r - T e n s io n . S o m e o f th ei nd iv i dua ls r ecogn i zed t h i s and exp l i c i t l y ca ll ed a t t en t i on t o a v i c ious cyc le o rpos i t i ve f eedback l oop w h i ch t ends t o exace r ba t e t he i r s i t ua t i on . Thus , f o rexam pl e , t he i nab i l i t y t o m ee t soc i a l dem ands w h i ch i s v i ew ed a s a r e su l t o ft he i r h i gh b l ood p r e s su r e i s be l i eved t o f eed back a s an acu t e s t r e s s f u r t he rexa cerba t ing the p erson 's il lness .

S i m i l a r l y , peop l e r ecogn i ze a s e t o f pe r m anen t , phys i ca l r e su l t s f r om t he i ri llnes s. These cons i s t o f p r i m ar i l y s t r oke , hea r t a t t a ck , a nd a w i de va r i e t y o fo t he r r e su lt s w h i ch a r e g r oup ed und e r t h e c l a s si f ic a t ion o f ' phys i ca l dam ag e . 'P r ob l em s w i t h b l ood ves se l s w e r e p r om i nen t i n t h i s c a t ego r y : va r i cose ve i ns ,' poo r c i r cu l a t i on ' re su l ti ng i n l eg pa i n , and aneu r ysm s w er e f r eq uen t l y m en t i one d .

G i ven t he h i gh p r o po r t i on o f soc ia l c ausa t i on , i t i s i n t e r e s t ing t ha t o f t he t w ocond i t i ons w h i ch r e su l t f r om t he se pe r m anen t changes , pa r a l ys i s and dea t h , t hef o r m er w as m or e w i de l y f ea r ed . D ea t h w as cons i de r ed p r e f e r ab l e t o a s ta t e o fpe r m ane n t i nva l id i sm , w he r e p eop l e w e r e pe r ce i ved a s be i ng t o t a l l y dep end en ton o t he r s , w i t h no op po r t un i t y t o exe r c is e any m ean i ng f u l soc ia l r o l e . Phys i ca ldea t h is p r e f e r ab l e t o soc ia l dea t h .

T H E E X P E R T ' S M O D E L

I n t he i n t r o du c t i on a p r oces s w as de sc r i bed by w h i ch i nd iv i dua ls com bi ne t he i ro w n i ll ne ss e x p e r i e n c e s a n d i n t e r p r e t a t i o n w i t h t h e p o p u l a r a n d e x p e r t m o d e l s


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2 1 4 D A N B L U M H A G E NTABLE 8Emotional Symptoms

NI . Psychological Sym pto m sNervous 8Temper 3Irritable 8Anxiety/Worry 3Upset 1Feel Stress 1Gets up tight 1Changed Behavior 1Tension 2Hyperactivity 1

Loss of Sleep 1Easily Distracted 1II. Changed Social Fu nctio nUnable to meet social demands 3Unable to work as well 3Unable to show restraint 1Ill at ease 1Altered behavior 1Relationships deteriorate 2

t o c o m e u p w i t h a s e t o f e x p l a n a t o r y m o d e l s o f t h e ir ilh ae ss es . W e h a v e d e m o n -s t r a t e d o n e w a y t o d e ri v e t h e p o p u l a r m o d e l . H o w d o t h e se li n k w i t h t h e e x p e r tm o d e l ? I t i s i m p o r t a n t t o r e m e m b e r t h a t t h e p h y s i c i a n is t h e p r i m a r y f o l k h e a l e rfo r a lmo s t a l l t he i nd iv idua l s i n t h i s s t udy . The do c to r ' s expe r t i s e i s s een a s t hes t a n d a r d b y w h i c h p o p u l a r a n d p e r s o n a l il ln e ss b e li e fs ar e j u d g e d . T h e s t a t e m e n t" Y o u s h o u l d n ' t a s k m e t h a t , I ' m n o t a d o c t o r " w a s r e p e a te d l y e n c o u n t e re d i nt h i s s t u d y . N o n e t h e l e s s , a l o n g t h e w a y w e h a v e p o i n t e d o u t i m p o r t a n t a r e a s o fd i f fe r e n c e b e t w e e n p r o f e s si o n a l a n d p o p u l a r b e l i ef s . W h a t t h e n i s t h e e x p e r tm o d e l o f h y p e rt e n s io n a n d h o w d o e s it r e la te t o t h e p o p u l a r m o d e l ?

Th i s qu es t i on , wh ich supe r f i c i a ll y appea r s qu i te e a sy t o answ er , i s i n f ac to n e o f t h e k n o t t i e s t t h a t f a c e s u s . C o n v e n t i o n a l w i s d o m w o u l d i n d i c a te t h a tw e s h o u l d l o o k i n t h e r e c o g n i z e d t e x t b o o k s o f m e d i c i n e , o r i n th e b i o m e d i c a ll i t e ra t u r e , a n d u s e t h e m o d e l s e x p r e s s e d t h e re a s p r o t o t y p e s o f t h e p r o f es s i o n a lm o d e l . T h i s o v e r l o o k s th e n a t u r e o f t h e m a t e r i a l p r e s e n t e d in e a c h o f th e s e t w op l a c es . T h e b i o m e d i c a l l i te r a t u r e i s p a r t o f t h e c o n s t a n t r e w o r k i n g o f t h e b a s ice x p l a n a t o r y m o d e l s a n d b e l i e f s y s t e m s o f m e d i c i n e . A s s u ch , a l m o s t a n y b e l i e fw ill b e e x p r e s s e d b y s o m e e x p e r t w h o m a r sh a U s d a t a t o s u p p o r t h i s v i ew . M o s to f t h e s e , o f c o u r s e , a re r a p i d l y f o r g o t t e n , e x c e p t b y t h e a r c hi v is t. I t i s a s s u m e db y t h e m e d i c a l p r o f es s io n t h a t o u t o f t h e c a c o p h o n y , t r u t h w i ll s o m e h o we m e r g e .


19/31

A F O L K I L L N E S S W I TH A M E D IC A L N A M E 2 1 5T h e a u t h o r s o f t e x t b o o k s a n d m o n o g r a p h s t a k e th e b a si c d a t a o f t h e b io m e d -

i cal l i t e r a t u r e and t hen r ew or k i t i n t o a be l i e f sys t em . Th ese a re ve r y ex t ens i vem o d e l s . A r e c e n t t e x t b o o k o f m e d i c in e , f o r e x a m p l e , sp e n d s 1 8 d o u b l e co l-um ned pages de sc r ib i ng hyp e r t ens i o n a l one ( Beeson , M cD er m o t t , Wy ngaa r den1979) . S i m i l a r ly , l ar ge m onog r aphs go i n t o eve r i nc rea s ing de t a i l to m ake a ll t heda t a f i t i n t o som e ove r a r ch i ng s chem a (e . g ., K ap l an 1978) . F r equ en t l y , f l owm o de l s s im i l ar t o t he one deve l oped he r e a r e p r e sen t ed . W ha t a re d i scus sed int he se sou r ce s a r e b e l i e f sys t em s , w h i ch i nd i v i dua l p r ac t i t ione r s m er ge i n t o t he i rp r ev i ous b e l i e f sys t em s an d w i t h t he i r c li n ica l expe r i enc e ( Mechan i c 1978) . Th i sp r o c es s m a y b e v e r y s im i la r t o t h a t d e s c ri b e d f o r l a y m e n , b u t h o p e f u l l y i t o c c u r son a d i f f e r en t leve l o f com pl ex i t y and cohe r ence ( G a i nes 1979) . A s ha s beendesc r i bed , t he exp e r t t hen use s t he se be li e f s t o shape an exp l ana t o r y m ode l t ogive to an indiv idua l pa t i en t .I n ad d i t i on , i t is m y expe r i enc e t ha t e xp l a na t o r y m o de l s a r e no t u sua ll yp r e sen t ed by a p r a c t i t i one r as a w h o l e a t one po i n t i n t i m e , bu t r a t he r p i ecem ea la s t he need f o r i n t e r p r e t a t i on o f t he i llnes s exp e r i ence ar is es . Seve r a l o f t hepa t i en t s i n t h is s t udy had had t he i r i ll nes s f o r t h i r t y yea r s o r m or e and had s eenm a n y d i f f e re n t p r a c t i ti o n e r s . N o t o n l y h a d t h e y s e e n d i f f e re n t p r a c t it i o n e rs , b u to v e r t h is p e r i o d o f t i m e t h e o v e r a rc h i n g b i o m e d i c al m o d e l s o f h y p e r t e n s i o n h a v echanged subs t an ti a ll y . U nde r t he se c i r cum s t ances i t i s i m poss ib l e t o s ay w h a tp r o fe s s io n a l m o d e l s h a v e b e e n p r e s e n t e d t o t h e m ( A m a r a S i n g ha m 1 9 8 0 ).

S i nce w e a r e u s i ng c r os s s ec t i ona l da t a f r om an ongo i ng p r oces s , t he on l ya l t e rna t i ve t ha t w e have i s t o ex am i ne t he m ode l s w h i ch w e r e cu r r en t l y be i ngpr e sen t ed i n t he c l in i c . Th e r e a re t w o sou r ce s o f ill ne ss ex p l an a t o r y m od e l s i nt h i s c l i n ic : t he t w o nu r se p r ac t i t ione r s s w ho w er e ac t ua l l y s eei ng t he pa t i en t s ,a n d a w i d e v a r i e t y o f p a m p h l e ts p r e p a r e d b y t h e A m e r ic a n H e a r t A s s oc i at io n ,Sea r le Pha r m aceu t i ca l Com pan y , and t he N a t i ona l H i gh Bl ood P re s su re Ed uca t i onP r o g ra m . A l l o f t h e s e w e r e i m p o r t a n t t o p a t i e n t e d u c a t i o n .

T h e p r a c t i t i o n e r s w e r e a s k e d w h a t t h e y f e l t w a s i m p o r t a n t t o t e a c h t h e i rp a t i en t s a b o u t h y p e r t e n s i o n . R e s p o n s es t o e a c h o f t h e f iv e c a te g o r ie s o f t h eE x p l a n a t o r y M o d e l w e r e o b t a i n e d . B o t h n u r s e p r a c ti t io n e r s f e l t t h a t t h e c a u s eo f H i gh Bl oo d P r e ssu r e i s unk now n . Bo t h s t a t ed t h a t s t re s s c an exace r ba t eH i gh Bl ood P r e s su r e bu t i s no t t he p r i m ar y cause . D esp i t e t h i s , bo t h s a i d t ha tt h e y w o u l d n o t t r y ~ o o h a r d t o d i ss u ad e a p e r s o n w h o b e l i ev e d t h a t s tr es sf u ls i t ua ti ons h ad caused h i s H i gh Bl ood P r e ssu r e . H e r ed i t y and ob es i t y w e r e s eenas con t r i bu t i ng f ac t o r s . Bo t h s t a t ed t ha t r e a sons f o r onse t o f t he d i s ea se a t ap a r t ic u l a r t im e w e r e u n k n o w n , a n d t h a t t h e y t h e r e f o r e d i d n o t t r y t o g iv e a ne x p l a n a t i o n f o r t h e t i m e o f o n s e t.

The pa t hophys i o l og i ca l exp l ana t i on i nvo l ved i nc r ea sed p r e s su r e ac r os s t hew a l ls o f b l ood ves se ls , w h i ch r e su l t ed i n na r r ow i ng o f t he b l oo d ves se ls . Bo t hb e l ie v e d t h a t p a t i e n ts u s u a ll y c a n n o t d e t e c t s y m p t o m s o f e l e v a te d b lo o d p r e s su r e ,


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2 1 6 D A N B L U M H A G E Nb u t a g a i n s t a t e d t h a t t h e y d i d n o t a t t e m p t t o c h a n g e th e m i n d o f t h o s e w h obe l i eved t hey cou ld , excep t i n so fa r a s such be l i e f s a f f ec t med i ca t i on t ak ingbehav io r .

T h e p r i m a r y t r e a t m e n t s w e r e d i e t a r y , w i t h s a l t re s t r ic t i o n a n d w e i g h t l o ssb e i n g m o s t i m p o r t a n t . F o l l o w i n g t h e s e w e r e m e d i c a t i o n s w h i c h t h e y e x p e c t e dpa t i en t s t o need fo r t he r e s t o f t he i r l ives . Adv ice fo r gene ra l goo d hea l t h wasr epo r t ed , spec i f i c a l ly r egu l a r exe r c i s e and s t opp ing smok ing .

T h e p a m p h l e t s , a s o n e m i g h t e x p e c t , d i f f e re d li tt le f r o m t h e o p i n i o n o f t h enu r se p r ac t i t i one r s , pa r t i cu l a r l y i n so fa r a s t hey we re unab l e t o g ive r ea sons fo rt he e t i o logy o r onse t o f an i l l ne s s . One s a id " In some peop l e , b lood p r e s su re i sn e a r l y a l w a y s h i g h er t h a n i t s h o u l d b e . " T h i s is a g o o d e x a m p l e o f h o w s h a ll o wthe exp l a na t i ons a r e t ha t c an be g iven by s t a t i s t i c a ll y ba sed m ed ica l t heo r i e s .E a c h o f t h e p a m p h l e t s s tr e ss e d t h a t e m o t i o n s w e r e n o t t h e p r i m a r y c a us e o fh i g h b l o o d p r e s su r e , a n d t h a t s y m p t o m s w e r e n o t a r el ia b le s ig n o f h o w h i g h ap e r s o n ' s b l o o d p r e s s u re m a y b e .

The pa thophys io log i ca l mechan i sms we re l a rge ly t he s ame a s t hose g iven bythe n u r se s . One i n t e r e s t i ng d i f f e r ence i n t he r ap i e s is t ha t m os t o f the pam ph le t ss t re s s ed m e d i c a t i o n s a s t h e f i rs t c h o i c e o f t r e a t m e n t i n s t e a d o f d i e t a r y ch a n g e s.[Th i s is i n con f l i c t b o th w i th t he nu r se p r ac t i on e r s a s we l l a s w i th m ed ica le x p e r t s ( K a p l a n 1 9 7 8 : 1 0 5 ) . ]

Seve ral o f t he pam ph le t s i nc luded c lo s ing s ec t i ons t i t l ed som e th ing li ke" w h a t a b o u t g e n e r al h e a l t h h a b i t s ? " T h e s e l e c t io n o f t o p i c s h e r e i s i n te r e s ti n g .One s ays , i n pa r t :

1. Ge t plenty of relaxation. Do n't wait until you are exhausted to start to rest.2. L ose weight (if your doctor believes yo u should) then maintain it at the level suggested.3. Avoid alcohol and to ba cc o. . .4. Settle y our problems so they do n't w orry yo u and interfere with you r rest and peaceof mind.5. H ave adequate sleep. To do this you may have to insist on a nap d uring the day(Curtis 1976).Th ree o f t he t op i c s he r e dea l w i th s t r e s s a s a c ause o f il lne s s de sp i t e t hes t a t e m e n t e a r l i e r i n t h e p a m p h l e t t h a t " I t i s a p o p u l a r m i s c o n c e p t i o n t h a t a

h y p e r t e n s i v e p a t i e n t i s a n e r v o u s , c o m p u l s i v e , n e v e r r e s t i n g p e r f e c t i o n i s t w h oc a n n o t s i t st il l . . . [ s o m e ] a r e t h e r e la x e d ; w e l l a d j u s te d , q u i e t , c a l m t y p e "0 b i d ) . T h u s t h e r e c o m m e n d a t i o n s f o r a c ti o n c o n f l i c t w i t h t h e t h e o r y o f i ll ne s sw h i c h h a d j u s t b e e n p r e s e n t e d .

T h e p r o f e s si o n a l m o d e l u s e d i n t h i s c li n ic c a n t h e r e f o r e b e d ia g r a m m e d a ss h o w n i n F i g u re 3 . I t i s o b v i o u s l y v e r y d i f f e r e n t f r o m t h e l a y m o d e l , p a r t ic u l a r l yin so fa r a s i t i s t o t a l l y unab l e t o g ive a s a t i s fy ing answer t o t he ques t i ons "Whym e ? " ; " W h y n o w ? " ( T a u ss ig 1 9 8 0 ).A s i f b e c a m e o b v i o u s t h a t t h e r e w a s a w i d e d i f f e r e n c e b e t w e e n t h e p o p u l a r


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A F O L K I L L N E S S W I T H A M E D I C A L N A M E 2 1 7EMOTIONS

K A C E R B A T E )

UNKNOWN NARROWEDC A U SA L F A CT O R S ~ B L O O DVESSELS/ /

(RARE)

K I D N E Y /FUNCTION

TUMOR

. ~ / f ( S Y M PT O M S , U N U S U A L )

BURDEN ON , (HEART FAILURE) HEART AND ~ HEARTB L O O D V E S S E L S ~ ~ A T T A CK(ATHEROSCLEROSIS)

~ ~ T R O K E

KIDNEY FAILURE

FIGURE 3 CLINIC MODEL OF HYPERTENSION

a n d p r o f e s s i o n a l m o d e l s o f t h e i l ln e s s , w e b e g a n a s k i n g p e o p l e i f t h e y w e r e a w a r eo f t h e s e d i s c re p a n c i e s . O f t h o s e w h o s a i d t h a t t h e y r e a d t h e p a m p h l e t s a t l e a s to c c a s i o n a l l y a n d w h o b e l i e v e d t h a t t h e i r i ll n e ss w a s p r e d o m i n a n t l y d u e t o s t re s s( N = 3 4 ) 6 8 % s t a t e d t h a t t h e y h a d n e v e r f o u n d a n y t h i n g t h a t d i d n o t a g re e w i t ht h e i r c o n c e p t i o n o f t h e i r i ll n e ss . I a s s u m e t h a t t h e s e p e o p l e a re s u b c o n s c i o u s l yf i lt e r in g o u t a n y i n f o r m a t i o n t h a t i s d i s c r e p a n t w i t h t h e i r e x i s t in g m o d e l . M o r ei n t e r e s t i n g ar e th e 3 2 % w h o s t a t e d t h a t t h e y w e r e a w a r e o f t h e d i f f e r e n c e s a n dconsciously r e j e c t e d t h e i n f o r m a t i o n , f e e li n g t h a t w h i l e a p a r t i c u l a r t h in g m a y b et r u e i n g e n e r a l , i t d i d n ' t a p p l y s p e c i f i c a l l y t o t h e m . A s o n e s a i d :Mo st o f the doc tors I ta lk to , some of them that I 've ta lked to are for i t and some are againsti t . . . I f i gu re in, someth ing o f t ha t r e spec t, you a r e wi th your op in ion and you can have it ,but i t do esn ' t necessar ily m ean th at I have to abide by i t . I can th ink and I 'm an in te l l igentbeing too and I can do research and read and come to my own conclusions about cer ta inthings, a nd just b ecause you disagree w i th m e, do esn ' t mean tha t one th ing is r ight and I 'mwrong. See? I t wou ld be di f ferent i f I came up aga inst a to ta l am oun t o f learned people whoin med ic ine wou ld say tha t t h i s is wrong , bu t you do n ' t . "

T h e p r o f e s s i o n a l m o d e l e x i s t s , b u t t h e p e r s o n w i t h t h e i l l n e ss r e t a i n s t h e r i g h tt o a c c e p t a n d r e j e c t t h e d o c t o r ' s i d e as . I n f a c t , b y f a r t h e m a j o r i t y o f th e p e o p l ei n t h is s t u d y h a v e d e v e l o p e d m o d e l s w h i c h v a r y w i d e l y f r o m t h a t h e l d b y t h e i rp r o f e s s i o n a l a d v i s o rs . W h y i s th i s ? S t r o n g s o c i al o r p s y c h o l o g i c a l f o r c e s m u s te x i s t w h i c h r e q u i r e a m o d e l o f i ll n e ss b a s e d o n s o c i a l s t re s s - o t h e r w i s e s u c h a' s u rv i v a l' w o u l d r a p i d l y b e o v e r c o m e b y t h e s h e e r w e i g h t o f B i o m e d i c a l o p i n i o n .

T H E U S E O F T H E P O P U L A R M O D E LT o a n s w e r t h e se q u e s t io n s w e m u s t g o b e n e a t h t h e s i m p l e p r e s e n t a t i o n o f th em o d e l a n d e x a m i n e h o w t h e p e o p l e i n th i s s t u d y r e p o r t u s in g th e m o d e l t oi n t e r p r e t t h e i r e x p e r i e n c e s a n d t o s t r u c t u r e b e h a v i o r a l o p t i o n s . D e s p i t e t h e f a c tt h a t t h e s e r e p r e s e n t reported a n d n o t observed b e h a v i o r , t h e y w e r e g i v e n a se x a m p l e s o f h o w t h e p e r s o n t h o u g h t h e a c t e d u n d e r c e r ta i n c ir c u m s t a n c e s. A s


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218 DAN BLUMHAGENsuch they demonstrate the conc eptual link between the cognitive models andperceived behavior. Much more extensive observa tion woul d be necessary todoc ume nt the links between cognitive models and actual behavior.

The m ajori ty o f the people intervi ewed (72%) report ed believing that 'Hyper-Tens ion' is a physical reflection of past social and en viro nmen tal stressors, whichis exacerbated by current stressful situations. Vignettes from the interviewsillustrate the way these concepts are used to define and redef'me experiences,and to ma nipul ate the social env iro nme nt to reduce stress.[Mental things] put a strain and stress and tight anxiety and this causes [high blood pres-sure]. I think that worry can cause - anticipations of something you have to do, I think thisraises it, too.Q. Is this what raised it in your case?Well, I know it raised it enough to put me in the hospital at one time . . . . I took a physicalaboard an aircraft carrier and it was fine and here come my orders back and I'm going toOperation Deep Freeze, to winter over [in Antarctica] to spend a year on the ice. I wentdown [for another physical] and everything was normal except my blood pressure and itwas way u p . . . So this does have something to do with it. I didn' t want to stay on that icedown there for a year.

Here even the t hreat of a pot enti ally disagreeable situati on was considere dto be enough to give this person his lifelong problem. It is not merely extra-ordinary events, but even the normal pressures of an occupation can build upto cause illness:Well, I been in t he . . , car business 30 years and that'l l drive you right up a t ree . . , with mypartner we had the largest Buick dealership in the state for ten years and I handled the cardesk - all the pressure's on the car desk .. . I had phone calls from [other states], I hadpeople from the office force coming in on the deals, I had seven or eight salesmen comingin on questions, I had sales meetings every morning. And that was six days a week . . . Ithink it was the normal things of the car business [that caused my high blood pressure].

Once the cycle of Hyper-Tens ion and high blood pressure is started, it affectsthe person's behavior:The slightest emotional problem sends my blood pressure up, and so I've got to constantlywork on it by myself and take deep breathing exercises and relaxing exercises... So I justwatch anything that distracts me to a point, and I'll just stop it. And even though I mighthurt the person's f~elingsI haven't got time to explain to them what I'm doing. SometimesI just walk off and take care of myself.

This person had had a 'nervous brea kdow n' for which he received psychiatrichospitalization and continues to receive outpatient therapy and medications.Despite the fact that his blood pressure was elevated before the breakdown (byhis ow n report) he feels his Hyper- Tensio n beame a probl em at that time andconti nues to be his ma jor pr oblem . As such, it permits the behavior he describeswhich otherwise w ould be socially unaccept able. A similar response was given


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A F O L K I L L N E S S W I T H A M E D I C A L N A M E 2 1 9

b y a p

blumhagen - 1980 - hyper-tension a folk illness with a medical name

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