Medical Anthropology, 25:265295, 2006 Copyright # Taylor & Francis Group, LLC ISSN: 0145-9740 print/1545-5882 online DOI:

10.1080/01459740600860063

Stress Knocks Hard on Your Immune System: Asthma and the Discourse on Stress
Betsy Pohlman and Gay Becker
Stress has been described by anthropologists and other scholars as a problematic concept, a discourse, a modern metaphor, a collective representation, and a cultural resource. The vast array of academic work in the arena of stress research belies the historical reality of stress as an object of inquiry; rather, stress is presented as new, the story of its emergence intermingled with processes of industrialization, individualism, and perceptions of modern life. This article traces the uses to which the concept of stress is put in the illness narratives of persons with asthma. It argues that multiple invocations of stress not only make visible the workings of personal responsibility and individualism regarding chronic illness management in the contemporary United States but also gesture toward the social relations of sickness that lie beyond individual control. Key Words: asthma; stress discourse

BETSY POHLMAN is currently a graduate student in the UCSFUCBerkeley Joint Program in Medical Anthropology. Her previous work at the University of Arizona in Anthropology included narrative analysis of perceptions of aging in the United States. At the doctoral level she is pursuing a comparative inquiry into the ethics and politics of care for Alzheimers Disease in old age and with Down Syndrome. She may be reached at 3333 California Street, #485, Box 0850, San Francisco, CA, 94143-0850. E-mail: epohlman@berkeley.edu GAY BECKER is a medical anthropologist and has a variety of research interests, including illness experience, reproductive technologies, health disparities, and aging and the life course. A persistent theme in her work is how people deal with disruptions to life. She is the author of four books and numerous articles. She may be reached at University of California, Institute for Health and Aging, 3333 California Street, #340, Box 0646, San Francisco, CA, 94143-0646. E-mail: gay.becker@ucsf.edu

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INTRODUCTION Notions of stress percolate through the illness descriptions and narratives of persons with asthma. Although the condition known as asthma has existed for centuries, its contemporary incarnation is replete with references to modern forms of living and its perceived complications. In popular texts designed to educate people about asthma, lists of potential triggers reference workplace substances, food additives, car and truck exhaust, and industry emissions, few of which would have been applicable as either trigger or cause in centuries past (see, for example, Berger 2000; American Medical Association 1998). Asthma is increasingly understood as an illness intertwined with human technologies and practices, including urbanization and development (DAmato et al. 2002; Jaakkola et al. 2004; Kheradmand, Rishy, and Corry 2002; Marshall 2004; Matricardi, Bouygue, and Tripodi 2002; Rydzynski and Palcaynski 2004; Smith and Mehta 2003; Wright 2004). Globally, incidences of diagnosis and treatment efforts are on the rise for both children and adults (Masoli, Fabian, Hold, and Beasley 2004). This increase is regularly described as an epidemic, a demographic that is only occasionally challenged (Holgate 2004; Isolauri et al. 2004; Shafazand and Colice 2004; Vargas et al. 2004). While some may argue that the diagnosis of asthma is applied more broadly now than ever before, what we can discern from the increase in diagnosis is that respiratory conditions and ailments have become profoundly common (for other respiratory diagnosis prevalence, see Salib 2003; Briggs 2004). Asthma is also a condition experienced differentially across ethnic groups, especially when group members are living within urban zones of poverty and marginalization (see Berg et al. 2004; Brown 2003; Finkelstein and Johnston 2004; McLean et al. 2004). African Americans, for example, are more likely to die from asthma than are their European American counterparts (Brookes 1994). Generally speaking, asthma is understood to be a chronic inflammatory lung disease characterized by hyperreactivity in lung airways that makes breathing difficult. Episodes of asthma are often linked to allergens or irritants, known as triggers. They can be experienced as events of sudden or gradual onset. Asthma can be fatal; however, biomedical practitioners consider the condition to be both treatable and reversible, meaning that the inflammation can be reduced, managed, or prevented through the use of (often)

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multiple medications (Brookes 1994; Lemanske and Busse 2003). Although there is no known single cause for asthma, tobacco exposure (first- and second-hand smoke), workplace irritants and exposures, and environmental toxin exposures are all considered to be related to the cultivation of asthmatic lung conditions. Although extensive genetic research has been undertaken with regard to asthma, there seems to be a consensus that multiple genes are implicated with none in particular being seen as a determining genetic cause (Ridley 2000; Vercelli 2004). The medical construction of asthma has a long history of associating the illness with the emotional life of those who suffer ita practice that locates causal responsibility with the diagnosed individual and her=his personality. As a result, asthma was defined as one of those diseases thought to be psychosomatic and has been researched as such (Abbott 1990; Becker et al. 1993; Helman 1985). Although researchers now reject the idea that emotions are a direct cause of asthma, a Medline search on the topic reveals an abundance of inquiries that bundle emotions and asthma together. Ones emotional state is construed to be a trigger for, a co-contributor to, or a product of asthma episodes (Brown et al. 2002; Lehrer 1998; Lehrer et al. 2002; Mrazek et al. 1998; Ritz, Claussen and Dahme 2001; Wright 2001; Zachariae et al. 2001). And, indeed, persons with asthma interviewed in this study associate their emotional responses to various situations and people as potential and probable triggers of asthma. During the 1950s and 1960s in the United States researchers in the emerging field of psychosomatic medicine were interested in the notion of stress as it was then being defined by Hans Selye. In fact, it was suggested that psychosomatic illness be renamed stress disease (Viner 1999). The configuration of asthma as psychosomatic, of psychosomatic illness as stress, and of stress as having something to do with modern life makes the discourse of stress within the narratives of persons with asthma especially interesting as a historical artifact. What is at issue is not whether or not asthma exists (it is real enough for those who suffer with it); rather, what is at issue is what the association between asthma and stress in the discourse of those who are diagnosed with asthma can tell us about an illness experience that also enables a critique of modern life. In this article we trace the uses to which the concept of stress is put in the illness narratives of persons with asthma. We argue that multiple invocations of stress not only make visible the workings of

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personal responsibility and individualism regarding chronic illness management in the contemporary moment but also gesture toward the social relations of sickness that lie beyond individual control. With regard to this study, we focus on the use of the stress discourse in narrative descriptions of asthma. It is beyond the scope of this article (and our expertise) to discuss in detail the neurophysiologic or biologic components of what has been conceptualized as stress in human bodies and lives. However, for those interested in these topics, two very interesting recent articles on diabetes begin to tease apart the relationship between stress and chronic disease (see Rock 2003; Schoenberg et al. 2005). And for those interested in a political ecological approach to asthma and urban geographies, Janice Harper (2004) has produced a helpful paper on this topic. In contrast to the aforementioned studies, our articles primary intellectual goal is to revisit and reanimate the conversation regarding the production of knowledge through the stress concepta conversation begun by Allan Young in 1980. First, we turn to the stress concept and review its history.

THE STRESS CONCEPT The notion of stress is historically entangled with inquiries and concerns related to shock, trauma, emotions, and memory. It emerged in the 19th century and was elaborated further in the aftermath of the First World War experience with shell shock (Young 1995; Abbott 1990). The conditions prevalent at the emergence of the stress concept associated the idea with the interaction between modern technology and human bodies. In his incisive and now classic critique of stress research, Allan Young (1980) argues that stress researchers produce facts about the social nature of humans by grounding their inquiries in the notion of an asocial and abstract individual. According to Young, empiricist understandings of social relations, a research setting that utilizes a division of labor and a set of social relations that resemble commodity production, and the research tools and techniques (e.g., life stress surveys) collaborate to produce facts that can only produce conventional meanings, i.e., ones resonant with the dominant ideology (134). The dominant ideology of which he speaks holds that the individual is the bearer of fixed psychological dispositions that are characterized by voluntarism. Society is construed by the

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researchers as merely a sum of the individuals belonging to it and as an entity that responds to individualized requirements (136). According to Young,
By displacing the human subject from his place in society to a desocialized and amorphous environment, the discourse banishes the arena of conflicting class and group interests from the real conditions of existence. In its place, the discourse substitutes a zone of anxiety within which the power to affect peoples well-being is diffuse and subjective (hence the emphasis on psychosocial supports, coping mechanisms, stressful life events), and change is constituted as a pathogenic environment-out-of-control. (133)

Youngs critique is complex, rich, and still relevant to stress research. Notably, he attempted to unpack the scholarly discourse on stress, paying particular attention to the then burgeoning stress research conducted by social scientists. His concerns for the public, or popular, aspects of stress discourse primarily concern sciences authorial power to use them to legitimate existing social arrangements (144). In the opening paragraphs of his commentary, Young reveals his assumptions about the pathways through which knowledge production travels. For him, knowledge is produced within the research frame and then is disseminated to the lay public. Facts are constructed and produced and become ever more social as the public takes them up. However, Russell Viner tells a story about the efforts of one scientist, Hans Selye, who, in garnering public support for stress research within the public realm, complicated its popularization. This story is worth repeating here. Amidst the variable 1930s conceptualizations of stress as anxiety, force, or shock, Hans Selye, conducting research in Canada, developed a physiologic concept of stress, holding that it was a universal truth for all organisms. According to Viner, from whom much of the following account is drawn, Hans Selye was the first to claim to have identified a physiological reaction that was the unitary response of all organisms to all environmental agents. This novel use of the term stress to denote the non-specific reaction rather than the external agents . . . formed the basis of Selyes claim to have discovered (and capitalized) Stress (Viner 1999:394). For Selye, stress was the physiologic adaptation of an organism to environmental influences. Viner argues that, during the interwar years (the time of Selyes initial research), researchers from both physiologic and social science disciplines were concerned with stabilityan effect of the instabilities associated with

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industrialization, the Depression, and the emergence of fascism in Europe (Viner 1999:398). Selyes physiologic work on adaptation resonated with these concerns. Selyes initial ideas were received well, but he got into hot water when he extended his concept of stress to a unifying physiologic theory he called reacton theory. He conceived the basic elements of life to be reactons, subcellular but supramolecular structures which were the smallest biologic target which can still respond selectively to stimulation. (Viner 1999:397). The essence of life, for Selye, was embedded in this response mechanism, and he had no qualms about transferring his theory to higher levels of organization, such as human society. Selye argued that, at group levels, altruism served individual self-interest by minimizing reactons and stress. He grandly suggested that the application of such intercellular behavior to the interpersonal and international levels could revolutionize human life, resulting in a scientifically grounded system of ethics and values that superseded all religions (398). When his colleagues refused his theoretical inclinations, Selye took his concept of stress on the road and presented it to anyone who would listen, engaging with the public in general as well as with specific influential groups. Viner, using a Latourian analytic frame, identifies several groups that Selye enrolled to back his concept of stress. This loose association of interested parties constituted a puzzling confluence of divergent groups, all of whom understood the concept of stress to be congruent with their own concerns. Viner argues that the renaissance of scientific stress research in the 1960s was a direct result of the allies that Selye had garnered through his prolific writing and public speaking in the 1940s and 1950s. It is this complex of associates and associations that assisted in producing the contemporary understanding of stress, a concept that Viner (1999:329) claims is today a deeply held modern metaphor, an unquestioned explanation of the darker sides of human experience. As mentioned earlier, largely due to a congruence between their theories of information and energy systems and Selyes concept of stress, Selyes earliest allies were those persons interested in psychosomatic medicine. But the flexibility of the concept, and Selyes manipulation of it, resulted in alliances with the U.S. military and capitalists.1 The militarys interest in the concept of stress had to do with concerns about battle fatigue and the idea that stress could be used as a weapon. Selyes idea that work constituted positive and necessary stress for humans interested capitalists, who

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wanted a more efficient workforce. Finally, people who sought alternatives to established medicine found stress to be a useful concept because it fit with their ideas about the negative effects of the built environment on human bodies. According to Viner (1999:401): In Selyes message, conservative America and industry saw a validation of their cherished beliefs in personal ambition and capitalist social relations, whereas for those critical of the direction of modern American culture and society, stress became a unifying slogan for the unnatural effects of modern industrial civilization. Through Selyes efforts to interest alternative practitioners, civilized health intimately became linked to stress reduction practices. Viner goes on to claim that stress re-entered science in the 1960s through the disciplines of psychology, translated . . . from a physiological syndrome to a part of narrated life experience that was seen to require psychological investigation. Stress had been translated from a story told to the masses by a scientist, into an experience told to scientists by the common person (402). Significantly, none of Selyes allies took up the stress concept in a way that directly contradicted Youngs critique of the concept of the ` individual vis-a-vis society. Selye, whose project began in the laboratory while he was working with animals, saw the social sciences as an opportune vehicle through which to disseminate his ideas. In moving from the physical sciences to the social sciences the concept of stress was altered so that it could apply to complex social relations. The concept was in the popular realm before the reinvigoration of stress research (Youngs subject of inquiry) in the 1960s. Although Viner argues that Selye more or less single-handedly popularized the stress concept, sociologist Andrew Abbott (1990:439) traces the popular notion of stress to 1900, prior to the emergence of positivist social science stress research. Abbott sees popular concepts of stress as forming a meaningful symbol:
In particular, the image of the stressed individual has its great meaning for us precisely because it binds anxiety and mind cure with social adjustment and performance, linking these with the larger antitheses between rationalization and mechanization on the one hand, and romanticism and individualism on the other. By this binding, the ambiguous image of the stressed individual gives us one of our only common and legitimate ways of talking about the problems of modern existence. A public that will not read the weighty writings of Spencer and Durkheim on these subjects will eagerly consume articles and talk shows that attack them via the question of stress. (442)

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Abbott analyzes the discontents of positivist stress researchers with regard to the stress concept and discerns that their concerns stem from the ambiguities inherent in the popular, or cultural, concept of stress. He claims that the cultural concept of stress informs and fertilizes the scientific literature and that the reason it persists, despite the problems it apparently poses for research, is precisely because its fertility is far greater than is that associated with the scientific concept of stress (Abbott 1990:451). Discerning who produces knowledge and social facts and how they do so is not easy. Yet, the discourse on stress reveals the multiple possibilities and configurations of argument that are available not only for researchers and elites but also for laypeople and varied publics. It is worth asking whether or not the stress discourse can break the bonds of voluntaristic individualism. And this is where our story begins: with the various ways persons with asthma use the stress discourse to describe their illnesses. METHODS The National Institutes of Health funded this interview-driven study, which is entitled Age and Illness Management in Later Life. Gay Becker, Ph.D., is the principal investigator. The projects purpose was to investigate the experience of persons over 50 who were suffering from asthma. This group included women and men who had been diagnosed with asthma since childhood, those who had experienced a remission of asthma in young adulthood only to have it return in older adulthood, and those who had been first diagnosed when they were over the age of 50. The study sample consists of 168 participants: 59 European Americans, 50 African Americans, 35 Latinos, 17 Cambodian Americans, and 7 Filipino Americans. More women were enrolled then men, with 66 percent of the study sample being female. Due to concentrations in enrollment, this analysis focuses primarily on interview data from the African American, Latino, and European American groups. Determination of asthma was based upon self-reports of receiving a diagnosis from a physician. The exclusion criterion was the known or observable presence of confusion or dementia. All interviewees (hereafter referred to as participants) were living in Northern California at the time of their participation in this study. The interviewers, all women, were matched by ethnicity to each group and recruited their own participants. This resulted in

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different recruitment strategies and styles. The interview protocol was flexible and open. Although interviewers were supplied with an outline of possible questions, they were encouraged to initiate a conversational style that elicited those themes that were of most concern to the participants. Most interviews began with a request for the participants to describe, in their own words, a recent asthma episode. The subsequent interviews were founded upon this initial elicitation. Each participant was interviewed on three occasions, with the first interview focusing on her=his health history and experience of asthma and the second and third interviews focusing on asthma events that occurred in the weeks and months between interviews. Interviews were conducted in the language and location of the participants choice. Once translated and transcribed, the interviews were coded thematically and organized using the qualitative software NUD IST1. This article attends to a small portion of the data generated by these interviews. It is primarily concerned with the ways in which people used the concept of stress when describing their asthma experiences, and it focuses on how they interwove this concept with talk of emotions. Of the 168 respondents in this study, with no prompting from the interviewer 78 (46 percent) used the stress concept in describing their experiences of asthma. The data suggest that there is little difference in the use of the stress concept among the three groups studied: African American, Latino, and European American. None of the questions posed within the protocol for interviews referenced stress as a concept. Typically, participants talked about stress when they were asked either about the causes of asthma or the triggers of asthma episodes. Occasionally, interviewers improvised by using the concept of stress within the context of an interview, usually when probing for a fuller explanation or responding to a participants description of worry or concern. This interjection of the concept usually resulted in the participant agreeing with the interviewer and starting to use the word stress, thus highlighting the problem of using the term within the interview format. These conversational moments tell us that both interviewer and participant share the stress discourse. However, they are omitted from this analysis as our concern is to focus explicitly on participants unaided uses of stress concepts and discourse. The interview schedule did not include many explicit questions about emotions or affect. The section of the interview schedule that elicited a description of a recent episode of asthma dealt primarily

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with physical symptoms, their progression, and decisions made in treating them. A number of questions loosely linked to emotions relate to emotions in general rather than to the emotional responses and experiences of the participant. This is significant, given historical notions about emotions as both the cause of asthma and as the trigger of asthma episodes. That participants continue to link asthma to their emotional experience remains something upon which to speculate.2 There are, of course, methodological limitations to this study. As an interview-only project, potentially important distinctions between what people say and what they do remain unaccounted for and unseen. However, the strengths of this study include the possibility of understanding how language functions when it is used to describe experience. The remainder of this article depicts in detail the complexity of the discourse on stress and how it is used by people with asthma. NARRATIVES OF ASTHMA EXPERIENCE When people speak of their experiences with asthma episodes, most describe the fear associated with the bodily sensations of inflamed airways and breathing difficulties. This fear is understandably intensified when the episode occurs suddenly, as is emphasized in the common phrase asthma attack. Some participants related the asthma experience to their own fear of mortality. Here are some brief descriptions of the sensations associated with asthma episodes:
And you know people just dont . . . if you dont have asthma, you dont have a clue of what it is like to have that feeling that you cant breathe. To me I would equate that as someone who is drowning. I would equate that in the same way. It is like you are fighting for air to breathe, and the first thought in your head is, oh, my god! You feel like, I dont want to say it but it is the truth, you feel like you can die, it is a scary thing. (African American woman, age 52) My heart was racing, and I couldnt breathe properly and I was gasping for air. You know when you have an asthma attack the sensation is scary because to me it is one of the closest things to feeling like you are going to die. It really is, because when you cant breathe you cant live. So . . . when you lose your breath it is just like that saying, you know, you take my breath away. That is not necessarily a good thing, it is a

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scary thing. I am not afraid of dying, but I dont want to die like that, choking to death. (African American woman, age 53) It panics. It is something you cant describe with words. It is so scary. Your life is fading away. People next to you want to help you but nobody can do anything for you. Some people give mouth to mouth resuscitation, but what works for me is a massage on my back; hold your hand, a prayer. That is the most they can do for you. Its different when you are bleeding, in that case somebody gives you a bandage and the bleeding stops. But this asthma is something that nobody can stop. (Latina, age 50)

Significantly, the fear does not end with the episode but moves into the overall experience of the illness, as the following participant attests:
One of these days its gonna be the last time, and you start thinking crazy things like that. That this could be it this time, you know. So you wonder how many times are you gonna get away with it. Theres people around you dying all the time that you know. So, and as you get older, you start wondering whos next, you know what I mean? Is your number going to be next? So it carries a total mental thing. (African American man, 52)

A common theme in the interviews is the sensation of vulnerability experienced during asthma episodes. This sensation extends to the mundane activities associated with how the participants manage their condition. One European American woman talked about developing elaborate strategies for dealing with the vulnerability she feels as someone living alone. Her strategies include calling friends when she senses she may be entering an asthma episode and asking them to call her back in half an hour. She also unlocks her front door at these times so that emergency personnel can enter without any difficulty. Another European American woman spoke of how her dependence upon an oxygen tank for her asthma increased her feelings of vulnerability:
I just dont feel like I could get out of the way of a bus if it was barreling at me . . . I live in a good, nice neighborhood, and Im not afraid around here at all, but if I were walking down a street, and I didnt know anybody, and it was a little bit of a shady area, I think I look like a sitting duck. You know, Im little and Im a woman and if I were alone, whatever, and now with an oxygen tank they know I couldnt get out ofyou know, I couldnt run. (European American woman, 54)

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A prominent aspect of the asthma experience is the use and efficacy of medications. Most participants in this study spoke eloquently about their experimentation, frustration, and ambivalence regarding the medications prescribed for managing their asthma. Their concerns are too lengthy to illustrate fully: suffice it to say that a dependency upon daily medications and the need to rely on hospitals for emergency episodes increases peoples sense of vulnerability. Some participants (mostly women) associate their need for medications with old age, and many report feeling self-conscious about having to use medications in public. They worry that their visible use of inhalers will make people think of them as helpless, sick, or disabled. The physical experience of asthma episodes, coupled with a general understanding that these are associated with specific triggers, compels the person with asthma to look around for what might have contributed to her or his most recent episode. In the absence of an obvious and familiar trigger, uncertainty emerges. People ask themselves what they might have done differently or what they could have avoided. As there are multiple possibilities for how and why an episode occurred all kinds of things become suspecteverything from the food one ate, to ones emotional responses to events, to a strangers perfume, to wherever one happened to be. This situation, in which some sort of agent is blamed for pathological and disturbing physical events, bears a great resemblance to the overall concept of stress (Young 1980). Generally, when it is perceived to be present and when an easily identifiable allergen is not visible, stress is invoked as the cause of an asthmatic episode. Some of our participants spoke of stress reduction techniques cited in educational materials available for the management of asthma and in the classes offered by clinics. It should not be surprising that stress discourse permeates asthma because, quite clearly, it permeates American culture generally. Our questions attempt to determine how persons with asthma participate in, reject, or complicate this ubiquitous discourse on stress. STRESS DISCOURSE
A statement about sickness is a moment in a process in which the speaker is producing knowledge for himself and others. Allan Young

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Following Michel Foucault we consider discourse to be a moving medium that has organizing capacity and that brings together power and knowledge. Associated with language, but not reducible to it, discourse comprises concepts, objects, strategies, and practices. It is characterized by multiplicity and possibility (Foucault 1990:100 101). One can think of discourse as forming spaces within which experience can happen, making, influencing, and limiting what can be said or done through that experience (Purvis and Hunt 1993). In this case, one can think of the stress discourse as producing something named and known to be stress. The purpose of a discourse analysis is to elucidate a specific discourses complexityits differentiations, contradictions, and connections (Foucault 1972:200). The statements made by those who participated in our interviews constitute moments, quick sketches composed on the fly, in which the speaker [produces] knowledge for himself and others (Young 1981). In this sense, they are heterogeneous compositions that are easily subject to decomposition at a later time, either during or after the interview. The stress concept is one strand in the heterogeneity of strands that comprise responses to asthma. Often, participants use stress in collaboration with other phenomena (such as immune systems or allergens) to explain how their asthma is caused or triggered:
Heres what I believe in. I believe that stress is a factor . . . But I think that that would tend to, and stress and your resistance to infection, whether youre, how your body, how healthy you are or otherwise, how rested you are, when your body has, your immune systems built up well, I guess Im saying. I think that has a lot to do with it. And so I think that stress knocks hard on your immune system, and so if you dont have enough sleep and youre stressed out, and youre not eating properly, and worried, I think that will just hit hard. And, you know, any little thing that happens. I really believe in that. (European American man, age 62) I can only relate to my own, and I think it is stress. It is emotional asthma. So we are back to that. And also from what they say the air quality, bugs, mice, that kind of thing, there are bugs in the air. Also chemicals, you know, allergies to foods, all thatlife. (African American woman, age 53) What do I think causes asthma? I think its a combination of allergens and, I think its mainly allergens. I think its genetic. I mean my one brother has asthma. I have another brother who has hay fever, I have another sister has hay fever. So I think its genetic, combination of that, and I think stress. (European American man, age 50)

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When our study participants tell us about stress, it rarely stands alone as a single causal agent for asthma; rather, it is woven into biomedically inflected discussions of allergens and irritants. Many of the participants use stress as an additive, a kind of tipping point in the physiologic experience of asthma. As a concept, stress is either loosely defined or largely undefined; however, it is commonly associated with emotional disturbances. Often, stress stands in for emotional force, amplifying the feelings a person might already be experiencing. This stress, the stress that contributes to asthma, is generally considered to be negative and damaging to the bodies and health of participants. In addition to invoking stress as a cause of asthma, participants also saw it as triggering asthma episodes. As a trigger, stress arrives on the diagnostic scene in a variety of forms through various physical, emotional, and social activities. It is often described in relation to structural constraints associated with resources or social locations, what one participant referred to as her survival situation. Stress can act quickly, contributing to a sudden episode, or it can be cumulative, the product of a general set of anxieties that have build up over time. Although in the illness narratives of persons diagnosed with asthma stress is consistently associated with causes or triggers (the latter being most prominent), it is also talked about in a myriad of ways, which reveals the polyvalence of the stress discourse. In the following sections we highlight these divergent associations, noting moments when participants discussed stress in terms of suffering, as pertinent to them as individuals, and as related to work or family. We also note their thoughts on the possibilities for stress reduction. Finally, some participants use the stress discourse in order to argue that stress is not responsible for their illness. We have included a discussion of this as well.

Stress and Suffering

For many participants, the physical suffering associated with an asthma episode is discussed in terms of stress:
I mean it is so frustrating to go down to that level, that is how I feel. Like, why do I keep suffering like this. But I know that until God says no, it is going to be something that I am going to suffer through. And I know that I should not question His will, but I do sometimes. Now you see I will most probably go to hell for that, but when you are stressing like that, who cares?

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All you want is relief . . . You dont care whether you go to heaven or hell. (African American woman, age 57) You know I feel fortunate. I have been fighting this asthma all my life, and I have some terrible, terrible things with it, and you wonder how you stay sane physiologically from all that stress from being sick and stuff like that. (African American man, age 52)

In addition to the physical suffering caused by individual asthma episodes, many talked about the stress and suffering associated with waiting for medication to take effect while in the middle of an episode. They recalled the need to endure the attack until the pain and fear had eased. Chronic pain related to other illnesses is described as leading to stress, which, in turn, leads to asthma episodes. And these episodes can lead to yet other illnesses. One African American woman described her tendency to develop bronchitis following an asthma episode, a situation that led her to get stressed out really bad. The cumulative effects of episodes are associated with a more permanent form of suffering. One 74-year-old European American woman spoke at length about the role that, throughout her life, stress played in relation to her asthma. She claimed that the principal cause of her asthma episodes was stress and that she had had some extremely difficult years as a divorced woman singleparenting teenagers. During that time she incurred much stress and experienced many severe asthma episodes. She noted that reduced airway function was now a permanent condition:
The damagefrom the constantthese long periods, I guess, seemed to have just reduced my air capacity. And I never anticipated that. Its like you have an attack and then you get better. But now better isnt very good. But I didnt know that then.

Physical suffering is not the only kind of suffering the participants associated with stress. The management of asthma, from the practical details of laundering sheets to sorting through insurance protocols, is described as stressful and overwhelming. For those without access to insurance, suffering is exacerbated by exclusion, the efforts to find health care, and the minimal treatment options offered to those without it. Even for those with insurance, managing ones illness during a time of physical distress can be extremely daunting as it can involve the expense of purchasing recommended

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items for altering ones home (linens, air filters, etc.), the cost of medications, and extensive dusting (which, some say, exacerbates the illness they are attempting to alleviate).

Stress and the Individual

Asthma was once thought to be a psychosomatic illness linked to personality and an individuals emotional response to surrounding phenomena. All of the participants lived through an era in which these ideas held sway, whether or not they themselves had been diagnosed at the time. Personality and=or ones personal responsibility for either stress or ones reaction to it is sometimes intertwined with discussions of stress as a cause of asthma. At times, the person with asthma is subtly blamed for her=his illness. Some think that being a stressful person is somehow related to the acquisition of asthma. The following is a potent example of how a personality type is often associated with asthma:
Yeah. Im thinking of people that Ive known have had asthma, had lots of big highs and then lows, but I dont get the big highs. I think, personally, I think Im on a medium high rather than a low. I very rarely get depressed. Might be the Prozac, you know! But even before that, you know, Im a very outgoing person . . . but people that I have known, I would say stress, more than anything. Children that seem to have asthma are children that seem to be kind of higher achievers. And if they cant get what they want, you know, theyll have an asthma attack. (European American woman, age 69)

This direct link between personality, stress, and asthma, however, is not as common as one might think, given the histories of both asthma and stress. Many of the participants who used a stress discourse associated with individuality presented situations that were quite nuanced, requiring them to discern just where their responsibility with regard to causing or managing their asthma lies. In the following example, it is unclear whether the personality type associated with being unhappy is intrinsic or is caused by stress:
Yeah, I think stress can trigger a lot of things. I mean, stress can trigger all kinds of things in people. Yep. And thats why they say an unhappy person will die before a happy person. Its that idea, that stress is bad for your bodybad for your heart, bad for everything. Including your asthma. (European American man, age 62)

Stress, in these commentaries, is almost synonymous with emotional reactions to people and events. Both emotions and stress

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are seen as either something one creates and is responsible for or as something initiated from outside ones body and, therefore, out of ones control. Stress and emotions stand in as some kind of forcea force that requires a response. What follows is one example of a participant positing personal responsibility for her worries. She was responding to a question regarding the cause of her illness:
And when I am very stressed or preoccupied. Earlier, in the years before last year, I had some problems also. Problems never cease to exist . . . I feel that I focus too much on problems. It preoccupies me too much and I feel that is what has hurt me also. I have to try and be calmer. (Latina, age 51)

In the pursuit of relief for their asthma symptoms participants often described how they tried to discern what they could control. If the trigger was the environment, then they had already lost control of the situation; however, if the trigger was perceived to be stress, then they had the possibility of gaining control of the situation:
If its not of a, you know, if its not, if the environment doesnt have any ofbecause sometimes, you know, like dust and things like that will bring it on. But if its just about me being stressed, you know, the situation that creates the stress level, then I . . . try to recognize it and deal with it, you know? Channel it, so it comes, likeyou know, be calm and take deep breaths and things like that. And kinda relax through it. (African-American man, age 58)

In this case, the stress is conceived of as self and the environment as non-self. These personal interventions are complicated, however. At some times emotional responses are attributed to the individual, at other times they are seen as structural and anonymous. The following statements were made by a 53-year-old African American woman whose family provided her with private insurance. She received unemployment and disability benefits, both of which were running out, and she talked about being stressed. In what follows she talks about what would and would not trigger her asthma:
Sometimes I can be in an emotional situation, and I will be fine, and I dont have a problem, but I dont know what type of emotional reaction . . . I mean it is usually about survival situation, and that gets me most, survival. I mean if you upset me I most probably would not have an attack or my dogs or somebody that will not do it to me. But if it is really emotional, if it is really self-infliction type thing . . .

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It is interesting when I am saying this because I never even really thought about that, but now that I am thinking about it and we are discussing it, it really is brought on by something that is very personal, very me. Like I went for a job interview yesterday and, knock on wood, I got the job and I most probably would not have an attack for awhile. I mean I can go to work and be stressed out at work and I will be fine. But if I have some kind of emotional. (African-American woman, age 53)

Another woman, a 51-year-old uninsured European American, oscillates between her own responsibility for stressing myself out physically and the homeless shelters where she often resides and in which the stress level is so bad that it makes my heart race and it gives me asthma real bad. Finally, participants invoked a very particular type of individuality when they described stress as causing or triggering their asthma. Many referred to aspects of their childhood, which included abuse (by parents or teachers), second-hand smoke, and conflicted family dynamics as examples of stress and as causing their asthma. In these cases, stress is a thread that is seen to weave its way through a life narrative. It is depicted as cumulative and as having a physical effect.

Stress and Work

As noted earlier, notions of work as a positive and necessary form of stress emerged in capitalist-inflected research on worker efficiency. In our interviews stress and the workplace were often joined, but not usually in a positive way. Work was invoked as a negative stress, one that often affected individuals with asthma to such an extent that they considered leaving their jobs. A 53-year-old African American woman (cited earlier with regard to facing the structural constraints associated with joblessness) commented upon her last job:
They come in with their moods and they lay it right down on your table, you know, in the house, and you feel it. The last job that I had, I was there for four or five months . . . now I am a stayer, I stay at my jobs for five years top at least, and the reason I leave them is for better not because of worse. But the last job, I just didnt go back, because it was awful. The attitude was high, it was 100 percent attitude. I said I am not working in here, and I did have asthma then, big time. Because I used to come home at night and be so stressed out because the environment was so negative.

Although a couple of the participants spoke of the stress of relatively high-paying positions (commodity trading, for instance),

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most who talked about stress in relation to work seemed to occupy lower-status positions and to have little control over the events of their day. Their commentary was mostly of a social nature, having to do with problems with bosses or co-workers. In a couple of instances people talked about the job itself as stressful (e.g., incessantly answering phones for a customer service line). For some, the stress of a job and its effects on their asthma were part of their rationale for leaving. However, for others, the same sort of job stress had to be put up with until an event such as retirement or a random transfer. This sense of needing to make do often emerged in relation to other social situations, such as being recently divorced and the having to earn money to support ones children. This latter situation was more familiar to the women participants than it was to the men. Two participants made an explicit connection between work stress, asthma, and discriminatory practices. A 66-year-old African American man spoke about the stress of his job in Texas, which he suffered because [he] refused to bow down. And, after elaborating upon his stress and his anxiety attacks, he concluded: I was stressed there, being a black person in a predominantly white society and I just . . . It got the best of me. An 83-year-old European American man spoke at length about the decades of discrimination he had suffered for being a Roman Catholic. He talked about this as stress, and he commented upon the effects it had upon his asthma.

Stress and Family

For the participants in this study, the most detailed use of the stress discourse involved descriptions of their family life and their overall social situation. Most of the participants who talked about stress in this way were women who described complex social relations involving marriages and divorces, and the exigencies of parenting young and adult children. Several of these women were parenting their grandchildren or were heavily involved in their lives due to problems being experienced by their adult children. Raising families in compromised neighborhoods, where shootings occurred and loved ones suffered, was the social backdrop for comments about stress. The serious illness of spouses, children, friends, and neighbors played into how participants depicted the stress associated with their care-taking responsibilities. In nearly all cases, stress was construed as being intransigent and unavoidable.

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In the following example the participant perceived her familys collective lack of support as a source of stress, and the concept of stress provided her with an opportunity for critical comment. After describing her husbands refusal to attend an asthma education class on her behalf, this woman went on to say:
He wont do it. And my kids were too busy. Okay. I think that the family should be fined. There should be a monetary thing there, that if they take the class and learn, actually learn how to help somebody instead of knocking them down, that people would get along better. Cause, you know, my significant, so-called other isdo you know what stress that would relieve me of if he knew which medicine to grab if I got sick? Or to fill up the oxygen? (European American woman, age 56)

When women described the dissolution of their marriages, they described the transition period as extremely stressful and as accompanied by the increased severity and frequency of asthma episodes. However, once the divorce was finalized, they talked about how both their stress and their asthma had been relieved. As Young noted earlier, much of the ideological impetus of stress research regards change as stressful and, therefore, as pathological. These womens descriptions suggest that, while they construe change as stressful, they found the results of change to be both psychologically and physically beneficial. Deaths of relatives and loved ones figured strongly in conversations about stress and asthma, as either cause or trigger. Many associated the onset of their asthma with the death of a family member. One woman described how her daughters illness and death affected her asthma:
There are stressful times, and it might be why my asthma was a little worse this weekend . . . When my daughter was dying, I had asthma around the clock. However, the house had a cypress tree and I was really allergic to cypress at the time. Because I would go to my daughters house, and if the windows were opened up, [Id] get sick, all the time. They had these great big cypress trees right behind their house . . . She had cancer, and she died eight years ago. And, yeah. So, you know. Thats because a stressful situation you get into, that you wheeze no matter what you eat. You know? I was wheezing around the clock, then. You know, high stress situation. (European American woman, age 57)

In this case, despite the fact that an obvious asthma trigger (the cypress tree) was present, the woman clearly believed that the

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stress associated with her daughters death was the most significant explanation for her severe asthma situation. This suggests that the stress discourse is occasionally used to emphasize what the person with asthma considers to be the most important aspect of the time during which he or she experiences asthma episodes. As a narrative strategy, the concept of stress functions to highlight the story that is considered to be most important. For many of these women, that story involves their familial situation.

Stress Reduction and Management

Stress is, above all, understood to be a problem for the person with asthma. And, given that it is seen as a problem, there is a sense that it can be resolved. The language of stress reduction is pervasive in the United States, from self-help advice to regular newspaper discourse. It is hard to avoid the feeling that stress can be reduced or even eliminated. Generally, stress reduction activities are spoken of as individualized activities, such as meditation, deep breathing, praying, and visualization. All of these activities are associated with the idea that, through strengthening ones mind, one can control the more disturbing aspects of an asthma episode. When stress is understood as a key trigger for asthma, then managing the former becomes the main strategy for managing the latter. Thus, when an episode does occur, it is the fault of the individual, who has failed to effectively manage the supposed underlying condition of stress:
Sometimes stress will do it, and I experience periodic stress from the travel, from peaks and valleys in my work flow. I think what triggers it more than anything else is sloppy maintenance on a day-to-day basis. I dont seem to be particularly allergic to dust, to cat hair, or a lot of the things that set off other people. My feeling is that my onset, when I first had it, came from stress, and my worst episodes came from stress. (European American woman, age 55)

Thus the individual blames herself for her asthma. However, the ability to reduce or manage stress is often contested as participants come to understand what they can and cannot control. I can control the dust, one woman exclaimed, suggesting that that was all she could control. When a doctor recommended that a 56-year-old European American woman reduce her stress, she responded: I think its because the doctor knows that I dont

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have backup, and I really get kind of stressed out. He doesnt want me stressed. Ha, ha. But thats really funny. You have no choice here sometimes. Later in the interview she linked her current stress levels not only to her family situation (which she described as complicated and conflict-ridden) but also to her childhood (which involved abandonment and abuse). Thus she historicized her stress as well as her inability to escape it. Medications for asthma, when perceived as effective for mediating pain, are sometimes thought of as stress reducers. On more than one occasion participants reported taking medication for illnesses other than asthma, such as depression or panic=anxiety disorder. Taking medications for these situations, they noted, reduced their stress, thereby reducing the incidences and severity of their asthma. Stress was also discussed in terms of assimilation, particularly when it was related to family members and their illnesses. Becoming accustomed to certain situations was seen as a type of stress reduction technique. As a 57-year-old European American woman commented: I think those mostly were triggered by stress or something happening in the family, like somebody got sick. So now most of my relatives are sick, so theres no you know, its an accepted fact. Although many stress reduction strategies are considered to be effective, some had profound social effects (such as quitting ones job or asking a problematic family member to leave the household). One participant linked structural equity, especially with regard to health care and housing, to happiness, which she then contrasted with stress:
Yeah. And it allwhen you have happy children, youre not gonna be so stressed. And when youre not stressed, youre gonna be able to cope with life. And when you can cope with life, youre gonna take your medicine, and youre gonna eatits alllike the cycle of life. And Ill say, Oh, my gosh, Im so happy I have such a nice place to live and a nice landlord, and before, I used to think, like, Oh, thats a luxury. But its just a right of life. Everybody should be happy. Everybody should have good health care. Everybody should be treated well by their landlord. Its not like somethingyou have to treat, or a luxury in life. Thats the way its supposed to be. (European American woman, age 50)

Stress Refutation
Stress is presumed to be a universal feature of contemporary life, and it is precisely because of this that it can be easily refuted in the case of

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illness. Of course, many individuals in our study did not initiate the concept of stress at all. And, interestingly, several people actively refuted it as a possible cause or trigger of their asthma, knowing (as they do through asthma classes and asthma literature as well as popular domains) that asthma is often associated with stress. These participants recounted all the stress they perceived and noted that it did not result in any asthma effects: If stress triggered it, I would be rolling on the floor, I would be wheezing all the time. But for me, I have to say no, stated one European American woman. When asked why she thought she had asthma, another woman responded:
I think it just happened. I mean, I could blame it on that stressful episode in 1978, but the stress is gone and everybody else I mean, theres a lot of people in the world that have stress. Not everybody they dont all have asthma. So . . . (European American woman, age 57)

Furthermore, some of our participants have had asthma for a very long time and have lived through multiple treatment protocols and philosophies. One woman conducted an experiment with her peak flow meter, a device for measuring breathing capacity. She invited her husband and all her friends to measure their lung ability and, in this way, came to realize that her lung capacity was significantly less than was theirs. This realization of physiological difference contributed to her sense of causation regarding various symptoms:
Im 66 now and I grew up in a time where asthma was considered a psychological disease. Not by doctors. But by the general public. When I was in college, people were always saying it was justyoure just stressed out, thats why youre having an asthma attack, and it wasthis like pop psychology time, where asthma wasnt taken very seriously, exceptI dont mean it wasnt by the medical profession, but it wasnt by people at large, the general public, even informed people or educated people seemed to think it was something you brought upon yourself. So I grew up with that idea. I mean, I knew that it wasnt true in my experience. But other people wouldnt take it very seriously. (European American woman, age 66)

This passage illustrates that, just as, for some participants, stress appears as significant within the landscape of asthma experience, so, for others, it does not. DISCUSSION We have shown how the discourse on stress is used in the disease and illness narratives produced by persons with asthma. We have

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detailed a partial genealogy of the stress concept and highlighted some of the myriad ways stress is taken up by persons who have asthma. Generally, the stress discourse is used to talk about both individual selves and illness management responsibilities within a larger social scene. Some questions that emerged included the possibility the stress discourse provides participants for making a critique of modern life. If these examples of stress talk do indeed constitute critiques (and it is not always evident that they do), then how far can these critiques be taken and what are their effects? An additional question raised is whether or not the stress discourse can break the bonds of individualist voluntarism. It is to these questions that we turn in this discussion. Allan Young has argued that stress research desocializes the individual and promotes a conventional knowledge about the voluntaristic nature of individuals. In contrast, in our interviews the stress discourse taken up by persons with asthma was used in highly divergent ways and marked interactions between people situated within complex, interdependent situations. Does this amount to a refutation of Youngs argument? Studies by Grace G. Harris (1989) and Kristian Pollock (1988) have elucidated popular uses of stress in order to challenge Youngs analysis of stress research. Harris argues that the stress concept is a cultural resource and symbol, functioning primarily to bridge medical explanations of illness causation and moral interpretations. She refers to stress a medico-moral term that joins mechanism and morality (Harris 1989). She also claims that, as a cultural resource, both physicians and patients alike have access to the concept of stress and collaborate in the clinic to create and elaborate a developing aspect of American culture (15). She distinguishes these conversations and collaborations, however, from the work of stress researchers described by Young and argues that, while stress research may be infused with psychological assumptions, her respondents use the stress concept to set limits to the amount of psychologizing they allow into their interpretations. She writes, In brief, my respondents seem more socially grounded than the professionals portrayed by Young (ibid.). Within the context of illness narratives Harris distinguishes between fact and value, associating the former with mechanical causation informed by medicine and the latter with morality. The stress concept, she argues, bridges the two and allows causal explanation and evaluative interpretation to meet and interpenetrate (Harris

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1989:18). Drawing upon these distinctions in challenging Youngs analysis neglects the fact that he is concerned with the production of scientific fact through stress research. In short, Harris separates culture from science and places culture (or cultural resources) in a distinctive domain from which individuals intentionally draw. The assumptions about the relationship between individuals and society that Young noted with regard to stress researchers are present in Harriss analyses as well. Naming stress as a bridging concept analytically separates it from both fact and value and, thus, accords it a functionality that was not evident within the interviews we conducted. Harris critiques Youngs analysis through the popular use of the stress discourse. This project is explicitly not his, and this makes her stance, coupled with her use of an explanatory model-type frame, problematic. Pollock, on the other hand, develops an analysis of stress that, although it is catalyzed by popular discourse, interrogates stress research itself and expands upon Youngs arguments. Contending that stress is a collective representation and social fact, Pollock reviews the methods and assumptions found in stress research and claims that its ideological underpinnings produce multiple frames. For her, stress research produces the individualism that Young so carefully elucidated as well as an understanding of modern society as dangerous, repressive, and=or pathogenic (Pollock 1988). According to Pollock, stress is a way of organizing a variety of ideas about the social order, and it can be taken up in various ways. In broadening Youngs analysis of stress research, Pollock moves toward a discursive formation that includes multiple strategic possibilities for researchers and various others. Noting that stress is often explicitly linked to modern societies and chronic illness, Pollock begins to unpack the problematic boundaries between the perceived natural premodern and the unnatural modern (388). Her approach maintains the science-to-periphery model of the production of knowledge. Despite this, however, she opens a pathway toward understanding the variability within the very robust discourse on stress. One question worth asking is how specific the use of a discourse such as stress can be to particular disease experiences. Harriss study included hospital or clinic patients who had mild to serious health conditions not impaired by severe pain, debilitating pain medications, or cognitive dissonance. Pollock was attentive to the disease experiences of multiple sclerosis, schizophrenia, and

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nervous breakdown. Asthma, a life-threatening chronic health condition whose symptoms may progress rapidly from mild to intense, generates great fear and anxiety about the possible nearness of death (Becker et al. 1993). Symptoms often arise suddenly and unexpectedly, last for variable amounts of time, and dissipate slowly. This often leads to a decision to take medically focused actions. In our study, participant use of stress suggests that it is one option among many that enables people to talk about and explore their disease experience. It tends to stand in for moments of ambiguity or interconnection and enables the person to acknowledge her or his own embeddedness in social forms, despite the feeling of isolation, vulnerability, and dread that asthma episodes tend to engender. As mentioned earlier, the medical understanding of what triggers asthma episodes attracts the discourse on stress to a profound degree because of its compatibility with complex notions of stress as a product of outside influence, stress as organismic adaptation, and stress as ubiquitous and mysterious in its effects. Yet any discourse has limits. Despite its long-term associations with modernity, the stress discoursein the minds, words, and practices of persons with asthmamaintains its systematicity as a local concept, good for describing local relations and interactions. Serious critique is largely limited to families, workplaces, and overall personal situations. It is rare for these participants to use the stress discourse to reference the divisions and disparities that cultivate concentrations of illness in particular locales and among certain communities. Although participants talk about triggers such as pollutants or other environmental toxins contributing to their illness, and express fears of being canaries in the mine, these concerns are regularly separated from their customary use of the stress discourse. Stress, it seems, is used in reference to other people; therefore, its ability to promote change through critique is limited. This is one of our major findings with regard to how non-scientists use the stress discourse. Pollock (1988:388) has noted that invocations of stress can serve to deflect attention from the limitations of modern medicine. Chronic diseases such as asthma are regularly regarded as modern phenomena that are on the rise everywhere but especially for those living in poverty. The discourse on stress and the larger biomedical story of outside forces as triggers promoting pathological events work to elide the fact that biomedical practitioners cannot cure

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asthma or, indeed, any chronic condition. The rhetoric of reversibility, the process by which inflamed airways are subdued through medication, is supported by the notion of stress as suffering and medication as relief. In summary, our study suggests the multiple directions the stress discourse can take in the popular domain when linked to a chronic illness such as asthma. As individuals sort through a perplexing and variable chronic condition, the stress discourse appears to be, at times, a useful medium through which to explore causality and explanation. In our interviews stress emerges as one discourse among many, and one collaborator in an asthma etiology. Stress is also a lens through which important stories may be told (e.g., the death of a family member, problematic work environments, and so on). Ultimately, the nexus of illness symptoms and experience is located in the body of the individual. Thus, the moment at which a complex and ambiguous stress discourse collaborates with the embodied experience of asthma can be understood as a phenomenon that is suffused with discomfort, agency, and constraint. ACKNOWLEDGMENTS This research was supported by the National Institutes of Health; the National Institute on Aging R01 AG16608; Age and Illness Management in Later Life; Gay Becker, Principal Investigator; and Susan Janson, Co-Investigator. Many thanks to Edwina Newsom, Anneliese Butler, Leilani Canalita, Carrie Friese, Pauline Ken, Nury Mayen, and Cotys Winston for their dedicated work on this project. Three anonymous reviewers provided us with cogent critiques. This article also benefited through expert editing by Medical Anthropologys copyeditor, Joanne Richardson. Her assistance is greatly appreciated. NOTES
1. Although we recognize that it would be helpful to unpack the term capitalists further, we are utilizing Viners terminology in retelling the story he weaves about stress. 2. Questions in the interview schedule that do address emotional feelings are as follows: For T1: How did you feel about getting asthma at that age (for persons with adult onset asthma)? How does your family (and friends) react to your episodes? How helpful is your familys attitude about your condition? Whom do you

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turn to for emotional support? For T2: How would you describe yourself? How do you feel about this time in your life? How does having asthma affect you with respect to your age? Has it affected how old you feel? Do you have any concerns about them or hesitation in taking them (about medications)? Whom do you turn to for emotional support? What would you say are the hardest things about having asthma? For T3: same as T2.

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