American Journal of Epidemiology Advance Access originally published online on November 9, 2005
American Journal of Epidemiology 2006 163(1):97-98; doi:10.1093/aje/kwj014
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Book Review |
Epidemiology and Culture By James A. Trostle
ISBN 0-521-79050-6, Cambridge University Press, New York, New York (Telephone: 845-353-7500, Fax: 845-353-4141, Website: http://www.cambridge.org/us/), 2005, 208 pp., $70.00 (Hardback)
Département d'anthropologie, Université Laval, Québec City, Québec G1K 7P4, Canada
(e-mail: raymond.masse{at}ant.ulaval.ca)
This book is about creating conversations and interdisciplinary dialogue between epidemiology and medical anthropology. In recent decades, an increasing number of public health institutions have appealed to specialists of the "cultural factor" to help them enhance their understanding of risk factors. At the same time, many medical anthropologists recognize that the two disciplines share an interest in how disease and risks factors vary in time and space among different populations, as well as within subpopulations of a single country. In this book, Trostle analyzes the origins of an integrated approach in anthropology and epidemiology, as well as its conceptual and methodological bases. One chapter is about unpacking variables and the assumptions underlying disease-pattern categories, such as person, place, and time. Other chapters address the cultural issues involved in measuring disease prevalence and anthropology's contribution to the design of disease prevention and health promotion programs. It includes many examples of projects integrating anthropology and epidemiology (such as the study of cholera in Latin America), which illustrate the potential for such integrated perspectives. The book closes with an analysis of lay and professional ideas about risk and the difficulties inherent in communicating about risk.
Although many epidemiologists recognize the importance of culture, they are not well acquainted with the connections between patterns of disease and patterns of culture. The influence of culture is evident in how people eat, work, conduct their sex lives, interact with contagious persons, or react to messages about healthy habits. Culture also influences the meaning of disease (e.g., the symbolic association of cancer with death or acquired immunodeficiency syndrome with homosexuality) or the social representation of the efficacy of biomedicine and alternative medicines. Culture also influences the very construction of diagnostic categories. Each cultural group develops a local nosography reflecting their beliefs about natural and supernatural causes, as well as their conception of the physical and mental symptoms associated with each disease. The work of culture can also be tracked in the construction of the Diagnostic and Statistical Manual of Mental Disorders (a topic not addressed in Trostle's book), as an ethnopsychology of the concept of mental disorders has shown. In short, there are many ways in which culture influences disease, and many of them are analyzed throughout this book.
However, culture should not be treated as a single monolithic variable. Social factors analyzed by social epidemiology may include variables such as income, job stress, social support, or marginality, while cultural epidemiology also refers to values, beliefs, and social norms. These cultural factors, says Trostle, cannot easily be reduced to variables that interact in quantified models or patterns of correlation. Epidemiologists must be aware that, when blurred and complex entities such as values or social representations are "engineered" through such shortcuts, a quantitative reductionism is necessarily at work. The challenge is then to unpack the assumptions underlying complex "variables" such as religiosity, people, or race. As Trostle reminds us, without explicit theories linking underlying processes to causal variables, the indicators used to monitor disease are meaningless. Does the theory stress that religiosity is best measured through indicators such as the presence of faith, the frequency of church attendance, or the respect of rituals? This book calls for the construction of "auxiliary measurement theories" that label the links between theory-based concepts and the indicators used to measure them. It suggests that qualitative methods are needed to better clarify the concepts and their interactions. That is crucial to understanding the social and cultural pathways through which race, religion, and social support influence health.
Multidisciplinarity is thus the main issue here. Many examples highlight the creative potential of interdisciplinarity. One of the challenges of transdisciplinarity is to achieve complementarity between an in-depth microanalysis of disease causality through detailed individual accounts and a macroanalysis of health-related social and cultural determinants at scale, summarizing multiple disease occurrences into patterns and flows. The author convincingly presents the contributions that qualitative data and methods, including fieldwork, can make to epidemiology. Field notes are not anecdotes. Ethnographically sensitive vital statistics can be developed. How qualitative and quantitative methods are articulated is therefore a major issue. Trostle believes that the challenge is to combine individual case reports and statistical accounts without distorting either one. Human behavior is contingent; society and culture play a major role in how people relate to risk behavior. Anthropology can help to formulate questions and definitions and to measure relevant variables. A "cultural epidemiology" reveals the ways in which measurement, causal thinking, and program design rest on the cultural assumptions underlying them. This book argues against reducing human cases to sets of variables. What is at stake, then, is the ability to recover persons—to retrieve their individuality—from the matrix of relations that continue to be established among variables. The contribution of anthropology is to recover the "missing persons" lost under the mass of variables.
The experience of those who work to build bridges between social sciences and epidemiology proves that criticism is as strong among anthropologists, who denounce a medicalization of medical anthropology, as it is from epidemiologists, who considers culture to be a mere bias in causal models. The author of this book succeeds in demonstrating how anthropologic methods and theories can help both epidemiology and the design of public health interventions adapted to local sensitivities and rationales. His study of risk perceptions and local knowledge could also make the book useful for health education programs. It shows that community-based programs provide an opportunity for anthropologists to act as mediators not only between different cultures but also between lay people and health professionals. Still, Trostle maintains that the complementarity between anthropology and epidemiology must include an acknowledgement of each discipline's unique and separate contributions.
ACKNOWLEDGMENTS
Conflict of interest: none declared.
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