is considered to be at risk for diabetes (ADA 1984). Recently, type 2 diabetes has been increasingly diagnosed in children and …
AN OVERVIEW OF
ANTHROPOLOGICAL APPROACHES
TO
TYPE 2 DIABETES
Gina L Brooks
INTRODUCTION
Type 2 diabetes, previously referred to as non-insulin dependent
diabetes mellitus NIDDM or adult-onset diabetes is a disease affecting
ten million Americans with as many as 5 million more unaware that they have
the disease ADA 1998 Compared to all diagnosed cases of diabetes, type
2 diabetes may account for as many as 90 to 95 of all cases of diabetes
Fact Sheet Insulin resistance, a disorder in which the cells do not
properly regulate insulin, usually causes type 2 diabetes Gradually, over
time, the pancreas loses its ability to produce insulin as the bodys need
for it rises Diabetes Fact Sheet Common symptoms associated with
diabetes include:
1 Frequent urination
2 Extreme thirst
3 Extreme hunger
4 Dramatic weight loss with increased food intake
5 Weakness, fatigue, irritability, and drowsiness
6 Blurred vision or changes in eyesight
7 Tingling or numbness in the fingers, arms,
legs, or feet
8 Frequent infections and slow healing of cuts and bruises
9 Itching of the skin or genitals Villarosa, 1994
There are several risk factors for diabetes A:
10 Person with a strong family history of diabetes,
11 Person who is markedly obese
12 Woman with a morbid obstetrical history or history of babies over 9
pounds at birth, or a
13 Pregnant woman between 24 and 28 weeks of pregnancy
is considered to be at risk for diabetes ADA 1984 Recently, type 2
diabetes has been increasingly diagnosed in children and adolescents and
correlations have been made between race/ethnicity in relation to risk for
type 2 diabetes Diabetes Fact Sheet
Anthropology, defined succinctly, is the study of humankind Medical
anthropology is a subspecialty within anthropology, which applies
anthropological theories and methods to questions of health, illness,
medicine and healing Brown, et al 1998 There are many approaches to
health and illness within the field of anthropology, such as
biological/environmental, ecological, ethnomedical, critical, applied and
political economic approaches Each of these share four essential
principles: first, illness and healing can best be
understood from a
holistic view with respect to complex interactions between human biology
and culture; second, disease is influenced by behaviors specific to
cultures and sociopolitical aspects; third, cultural filters of beliefs and
epistemological assumptions are used to interpret the human body and
symptoms associated with it; lastly cultural characteristics of our healing
systems have important pragmatic consequences for the acceptability,
efficacy, and improvement of health care in human societies Brown, et al
1998:12 These four principles can be directly applied to current
anthropological research on type 2 diabetes
To date, much of the research that has been done on type 2 diabetes
has focused on issues relating to compliance and diabetes self-care
behaviors, focusing on patient attitudes with specific emphasis on
education and motivation Hunt et al 1998 Additionally, the utilization
and examination of patients explanatory models has been incorporated to
understand the sociocultural and personal aspects of the sickness narrative
from the patients point of view Poss et al 2002 Ethnographic studies
have provided insight into the sociological power structures within
medical
institutions and interactions between patient and provider Ferzacca 2000,
Hunt and Arar 2001 and Loewe and Freeman, 2000 The field of medical
anthropology is a subspecialty that has much to offer by focusing on the
sociocultural parameters of health, which includes an analysis of the
influence of cultural beliefs on health Olson, 1999 ultimately rendering
a much larger analytical framework
I have chosen to focus on the field of type 2 diabetes for a number
of reasons, both personal and educational As an African-American woman, I
have witnessed the effects of type 2 diabetes both within my immediate
family and among friends and loved ones It is my hope that in researching
current work on diabetes, I will be able to offer some suggestions for new
approaches to this devastating disease
METHODOLOGY
A literature review was conducted using Michigan State Universitys
Electronic Resources MEDLINE and FirstSearch, the National Library of
Medicines PubMed database, and MAGIC, the MSU Librarys online catalog
Searches were concentrated within five popular anthropology journals
Culture, Medicine and Psychiatry, Medical Anthropology Quartlerly, Social
Science and
Medicine, Anthropology and Medicine, and Medical Anthropology
published within the last decade Articles were selected after reading
abstracts and obtaining relevant articles for this review A brief summary
of my search is outlined in the tables below
MEDLINE
|Search |Terms |Results |
|1 |Diabetes and explanatory model|5 |
|2 |Diabetes and anthropology |71 |
|3 |Diabetes and medical |18 |
| |anthropology | |
Additionally, I retrieved a couple articles from journals targeted
toward a clinical audience and surveyed the American Diabetes Association
website http://wwwdiabetesorg/, and the Centers for Disease Control
website http://wwwcdcgov/diabetes to elicit common clinical and
epidemiological approaches to type 2 diabetes within the biomedical system
Articles retrieved were grouped by common themes centered on three
medical anthropological approaches, which I will be discussing further in
the next section
THEMES IDENTIFIED
|Theme
|Article Yield |
|Diabetes management, self-care, |6 |
|compliance | |
|Explanatory Models Ems |3 |
|Patient/Practitioner Analyses |3 |
|Other application of medical |2 |
|anthropology | |
DISCUSSION
Compliance
One of the major problems that arise for persons working with
patients with type 2 diabetes is the problem of non-compliance Ferzacca,
2000 Since this disease is such a chronic illness with long-term effects,
patients often must make lifestyle changes in order to manage their
illness Compliance can be defined as the extent to which patients
behavior coincides with medical advice Hunt et al 1998 As a matter
of interpretation, there are two extremes of the compliance spectrum On
one hand, medical compliance is thought of as an principle that reifies
medical authority, a concept at the bedrock of clinical practice and
American biomedical
systems On the other hand, compliance can be
considered as a balancing act between patient and provider, where the
patient is viewed as an active participant making life adjustments that
parallel his/her day-to-day lifestyle
The articles retrieved largely focused on patients perspectives of
management, self-care practices, and compliance in contrast with the
physicians recommendations and medical advice to unpack some of the social
values laden within medical practice today Ethnographic data was
collected in various medical settings using qualitative methodology and
open-ended interviewing techniques Four of the five articles retrieved
focused on the integration of treatment recommendations into patients
everyday lives Hunt et al, 1997, 1998, 2000 cult med 13 Based on the
information presented, patients in the study make constant and ongoing life
adjustments based on the patients explanation of an illness in addition to
the ability to feasibly include recommended treatments into their daily
lives Unlike epidemiological approaches, which seek to educate and
motivate, there was no correlation between improvements in knowledge base
and increased compliance Hunt et al 1998
Socioeconomic factors such as
lack of income and access to care often contend with a patients ability to
receive regular care and medical supplies Additionally, patients
fulfilling particular social roles ie female heads of household must
balance their responsibility with the demands of preparing meals for many
family members whose needs may not coincide with the recommended diabetic
diet
Three of the 4 articles on compliance specifically centered around
Mexican Americans, who suffer from type 2 diabetes at a rate 2 to 3 times
higher than that of the general population Hunt, Pugh and Valenzuela
1998 The articles assessed patients perceptions use of insulin therapy,
herbal treatments and prayer within self-care techniques These articles
were particularly effective in disproving common misconceptions and
stereotypes among physicians seeking to explain common causes of non-
adherence to treatment recommendations While 84 of participants in a
convenience sample of 43 low-income Mexican Americans had heard of using
herbs to treat type 2 diabetes, two thirds said they never tried this
method of alternative medicine Hunt, 2000 Despite these findings,
governmental agencies such
as the Centers for Disease Control name certain
cultural beliefs among psychosocial barriers to care which must be
prevented, detected, and treated CDC Guide for primary care
practitioners Contending views of effective approaches to type 2
diabetes care may be resolved through an integrative approach to care based
on patient and providers goals, careful examination of attitudes often
associated with particular ethnic groups, and consideration of social and
political factors influencing treatment options and choices
Explanatory Models
Within the field of medical anthropology, Arthur Kleinman, Leon
Eisenberg, and Byron Good are three names classically identified with the
term, explanatory model, which is characterized by five elements, which
describe:
1 The cause of sickness,
2 Circumstances surrounding the initial onset of the sickness and
relevant symptoms,
3 The physiology of the sickness,
4 The expected course of the sickness and appropriate behavior, and
5 Available treatments Hahn 1995
Within the clinical setting, explanatory models are formed and employed
to cope with a specific health problem Sargent Johnson 1996:121 but
are limited in their ability to shed
light on the sociocultural aspects of
illness and disease
The articles that fell in this category offered insight on both
cultural and social meanings of type 2 diabetes to arrive at a better
understanding of treatment approaches of this disease Two of the 3
articles were directed at Mexican Americans explanatory models of type 2
diabetes Poss 2002 and Hunt 1998, while the third Cohen 1993 compared
and contrasted patient and practitioners explanatory models, demonstrating
the degree of variation present between these two groups The Poss article
was of particular interest, as it synthesized ideologies pertaining to the
role and meaning of susto, or fright among a group of 22 Mexican
Americans diagnosed with type 2 diabetes
Susto, translated as fright or scare is normally classified as a
culture-bound syndrome, defined by Kleinman as an illness created by
personal, social, and cultural reactions to malfunctioning biologic or
psychological processes understood within defined contexts of meaning and
social relationships Poss 2002 Susto may present a wide range of
symptoms and is believed to be attributed to a wide range of illnesses As
Mexican Americans move through the
permeable boundaries of folk and Western
medical systems, speculations arise in relation to explanations of
patients onset of type 2 diabetes In the study, all but one subject
linked a specific episode of fright, or susto, to the onset of diabetes
Incidents causing susto included car accidents, a sudden death in the
family, witnessing a death, or being threatened by a gun Poss 2002
There was a discrepancy between participants in explaining the cause of
diabetes based on the setting they were in Participants were more likely
to attribute biomedical factors to the onset of diabetes within a focus
group, yet maintained that susto was the cause of diabetes when asked in a
one-on-one interview This demonstrates the level of fluid boundaries
between folk medicine and US biomedical systems that this particular
group of Mexican Americans moves between
Recent biomedical studies have examined a possible link between
psychological stress and type 2 diabetes More specifically, Scheder in
1988 found that Mexican Americans who experienced a greater number
stressful life events were more likely to have diabetes Poss 2002 Since
this data was cited as a secondary source in the Poss
article, the specific
details of the study are unknown However, anthropological studies are
making headway towards a fuller understanding of the social, political, and
economic factors contributing to the onset of disease
The last two articles in this section also focused on the question of
Why me? A study of 39 patients with type 1 and 2 diabetes and 15
professional staff at a University outpatient clinic revealed the degree of
congruency and variation between patient and practitioner when asked six
guided, open-ended questions based on the 5 major elements of the
explanatory model While there was a great degree of incongruence between
patient and practitioner regarding difficulties, time and mode of onset,
severity, etiology, and pathophysiology of diabetes, patients and staff
largely agreed upon modes of treatment Cohen et al 1994 I have included
a figure from the study to more clearly illustrate the contrast between
patients and providers within these 6 topic areas
The final study on Mexican Americans causal stories of diabetes
illustrates the use of both biomedical and idiosyncratic factors related to
the onset of diabetes Hunt, Valenzuela, Pugh 1998 In all
three
articles, patients were able to present specific events in connection with
the onset and diagnoses of their diabetes In addition, behavioral factors
such as lifestyle, diet, and level of stress were also cited as attributing
factors These congruencies represent the importance of the storied
narrative, which allows the patient to understand their disease in a way
that is personally relevant Physicians should realize that these causal
stories are constantly modified throughout a patients course of
interaction with type 2 diabetes Physicians are encouraged to elicit
explanatory models in order to efficiently understand the logic behind
their patients thinking and dispel some of the myths that may be
encountered
Patient and Provider Analyses
While patient explanatory models eclipse physicians approaches to
type 2 diabetes, contrasting views may shed some insight on divergent
approaches within the medical system As previously mentioned, non-
adherence to medical recommendations has largely focused on patients
knowledge and motivation toward treatment measures However, careful
consideration to the nature of the doctor-patient relationship presents two
different
analytical frameworks and sets of goals The ethos of medical
practice centers on pathophysiological factors such as blood glucose
levels, weight, and pancreatic function Conversely, patients place
emphasis on social factors such as the ability to function independently or
be perceived as normal
Clinical studies utilizing qualitative interview methodology and
participant observation were the primary methods of data collection in the
three articles retrieved Hunt et al 1998; Hunt and Arar 2001, and Loewe
and Freeman 2000 I first turn to the physicians perspectives of type 2
diabetes management and contrast these views with that of the patient By
and large, physicians treating type 2 diabetic focus on number successes,
based on glucose levels, and risk of internal complications such as kidney
failure and heart disease while patients focus on the social factors
assessed by how they feel and capabilities of performing everyday
activities Hunt et al 1998 and Loewe and Freeman 2000 While
complications entered into the minds of the patients, complications that
would in some way inhibit or restrict ability blindness, amputation of a
limb were of notable concern Physicians
would be more effective at
treating their patients diabetes if they sought out ways to understand
modes by which the disease effects the social skin Loewe and Freeman,
386
Clinical aspects of control cast a moral shadow over patients who
struggle with cyclical patterns and highs and lows in glucose levels The
concept of control for providers pits the patient against his/her own body
in an ongoing struggle to keep his/her blood sugar under control Patients
who are aware of the significance of the numbers find ways to appease
their physicians in time for medical check ups by fasting or exercising
before an appointment Ferzacca 2000 Deviant patients are viewed as
compulsive or stigmatized as being out of control based on a singular
clinical encounter noted on a inanimate object the chart that is used to
evaluate the patient Ferzacca 2000 One physician revealed, if they are
not checking their blood sugar or if they are not taking their medicine or
being compliant patients - they are sometimes almost threatened to be
kicked out of the diabetic clinic Loewe and Freeman 394 Such actions
point to rigid expectations within the biomedical system
Diabetes patients are
constantly being subjected to the medical
gaze, which can be thought of as a noun or more significantly as a mode
of action in which the gaze does, acts, moves; it is a gesture, not a
thing Rhodes 136 The patient is left to shield himself from the
penetrating gaze of the physician in an effort to circumvent being deemed
incompliant Physicians often resort to scare tactics, threatening the use
of insulin as a catalyst to bring patients actions in line with their
recommendations, ultimately reinforcing negative attitudes toward insulin
therapy Hunt 1997 rather than eradicating them
Biomedical Approaches
An overview of anthropological approaches to type 2 diabetes would
not be complete without contrasting a brief summary of techniques within
the field of biomedicine An initial visit to the Centers for Disease
Controls Diabetes Public Health Resource web page illustrates the
following logo: DIABETES: serious, common, costlybut controllable
In the foreground are pictures of a pair of running shoes, a bag of
healthy groceries, a glucose log sheet, blood pressure cuff, and a globe
While the globe may correlate with the commonality of the disease, the
seriousness, and
costliness of diabetes are perhaps conveyed through the
use of a blood pressure cuff and the bag of groceries
Further investigation led me to a listing of publications and
products related to diabetes A publication aimed at primary care
practitioners dealing with psychosocial problems caught my attention
Practitioners are encouraged to prevent, detect and treat the psychosocial
problems related to diabetes by any means necessary It is suggested the
practitioner should strive to establish an ongoing, therapeutic alliance
with the patient The stronger the alliance, the more likely the patient
is to share inner concerns and psychosocial issues CDC Guide for Primary
Care Practitioners Such tactics trigger thoughts of conspiracy rather
than caring - and this is only the first section On the issue of
detection, indicators such as recurrent hypoglycemia and high levels of
glycosylated hemoglobin should each be recognized as a possible sign of
personal or family problems CDC Guide It becomes unclear whether the
physician should act a provider or counselor when he is encouraged to
conduct discussions about problems on a wide range of issues from mood,
anxiety and well-being to
topics that patients may be hesitant to talk
about, such as sexual problems since the practitioner may then be able to
counsel the patients and provide useful solutions CDC Guide Herein
lies an example of the physicians professional roles run amok These
physicians most likely lack the skills necessary in addressing the wide
range of topic areas they may unearth by digging into their patients
personal life Furthermore, the degree to which physicians are encouraged
to develop close relationships with their patient is probably unlikely
within the time constraints of an abbreviated medical check up This does
not include physicians who work in urban clinics who may treat the same
patient once or twice over an extended period of time
An article that appeared in the journal Geriatrics, offered an
analysis of the ADAs clinical practice recommendations using an evidence-
based medicine perspective The ADA presented similar management plans to
the CDC relating to control over glucose levels through therapeutic
alliance and motivation on the behalf of the patient Strano-Paul 2000
However, no discussion of psychosocial problems was presented in this
article apart from considerations
relating to patients age It is
interesting to note that the basis of evaluating the validity of the ADAs
recommendations is tautological, using recent findings, which link improved
blood glucose control to reduction of complications such as nephropathy and
neuropathy The basis of this analysis does not look to approaches outside
of biomedicine but rather, draws upon biomedical indicators glucose
levels as a means of validation
CONCLUSION
Where do we go from here?
A wide range of approaches to diabetes has been identified and
presented both within the field of anthropology and without Cultural
approaches draw upon cultural beliefs, customs, values and cultural systems
while political economic approaches focus on the affects of relationships
of power and economic organization in relation to sickness and disease An
integrative method of approaches would be more effective in studying
diabetes from every angle Many of the articles suggested that research
should be done on the role of socioeconomic factors on diabetes as well as
racism, poverty, and race/ethnicity Largely, research on anthropological
approaches to diabetes has focused on ethnic minorities such as
Mexican
Americans and American Indians, who suffer from type 2 diabetes at
disproportionate rates African Americans also suffer from diabetes at
higher rates than their White counterparts Bailey 2000 yet I was unable
to locate anthropological articles specific to this group Bailey
presented a focus group study that I encountered in my independent study on
Women and Diabetes, which characterized the beliefs and practices of Black
women with type 2 diabetes I would like to further investigate whether
there have been any studies relating to perceptions of health in relation
to incidence of type 2 diabetes to elicit whether these perceptions play a
role in self-care practices and health seeking behavior Qualitative
research methodology using open-ended interview questions has proven
effective in obtaining meaningful results that empirical studies cannot
always achieve Its holistic approach is useful in understanding the
context of humans in their environment as well as understanding the human
experience within the interconnected world wherein we live While the task
at hand may be difficult at best, much can be learned from each fields
methods of approach rather than looking to
exclusive means only
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