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To the Instructor
Teaching medical anthropology is both exciting and
challenging. Undergraduates are able to relate to sick-
ness and healing because they have had some lim-
ited experience with them. Of course, many of your
students are thinking of careers in the health care
industry. Learning about the multiple causes of dis-
ease and the cultural variation in healing practices
makes students examine their own lives and culture
with a fresh perspective; one of the real satisfactions
of being a teacher comes from watching students get
excited by such an intellectual journey. It is also sat-
isfying when students become increasingly aware of
the health problems of others, especially the poor at
home and around the world. At the same time, teach-
ing medical anthropology is challenging because of its
amorphous nature and the astounding growth of the
body of theory and knowledge. How does a profes-
sor organize such a course? How do you decide what
examples to use?
This book is divided into two main parts. Part
I illustrates the variety of theoretical and analytical
approaches used by medical anthropologists. Part II
provides examples of those approaches as they relate
to a variety of health issues and problems; hence the
title of the reader—Understanding and Applying Medical
Anthropology. The first part of the book makes apparent
that we hold a very broad view of the scope of medical
anthropology and that we are committed to the tradi-
tional four-field approach of general anthropology. We
believe that the application of anthropological knowl-
edge—the job of making our research useful—is part
of the responsibility of all anthropologists. Aspects of
nearly all anthropological work are relevant to under-
standing and solving human problems. That is why
we use the term applying medical anthropology rather
than the narrower and more specific applied anthropol-
ogy (in both this and other edited readers). The latter
term refers to anthropological work done by an applied
anthropologist for a client on a problem identified by
the client. We think students want to read about anthro-
pological research and analysis on relevant topics, and
the second part of the collection provides some good
*The reference listings for all citations in To the Instructor, To the Student, and all chapter introductions and Conceptual
Tools sections are in the References section at the end of the book.
examples of such work. At times we have included
two or more selections on a similar topic in order to
enhance in-class discussions. Thus the organization of
this book suits a heterogeneous approach to a medical
anthropology course.
As far as we can tell, there is no agreement about
how a basic course in medical anthropology should
be taught. Almost 35 years ago, the first special pub-
lication of the new Society for Medical Anthropology
(SMA) concerned teaching medical anthropology; the
volume included nine different model courses (Todd
and Ruffini 1979*). The diversity of those courses—
ranging from ethnomedicine, to biomedical anthro-
pology, to family structure and health—was impres-
sive. Today, the SMA website has a section on teaching
resources that includes more than 50 syllabi.
Theoretical diversity has been a continuing hall-
mark of medical anthropology, and its importance is
reflected in most of the edited textbooks of the field.
However, the relatively few regular textbooks in the
field have had, by necessity, a more narrow theoreti-
cal focus, such as the ecological approach (McElroy
and Townsend 1996) and the cultural aspects of heal-
ing and medicine (Foster and Anderson 1978; Helman
1994; Strathern and Stewart 2010). Recently some new
books have provided a synthesis of medical anthro-
pology, even as the discipline has expanded and the
theoretical basis of research has become more sophis-
ticated (Anderson 1996; Hahn 1995; Janzen 2001;
Joralemon 1999; Nichter 2009; Singer and Baer 2012:
Wiley and Allen 2008; Winkelman 2008).
The first and second editions of this book were
well received. There is a need for a reader in medical
anthropology that includes original research articles
that can accompany the texts, ethnographies, and
case studies that we use in such courses. As we have
collected course syllabi from other medical anthro-
pologists over the years, we have been struck by
the diversity and richness of the teaching resources
available. For the first edition, we thought it would
be easy to assemble such a reader, but it turned out
to be quite a difficult task—partially because of the
8 To the Instructor
expanding breadth of the field and partially because
there are so many fascinating articles available. Our
first list included more than 220 articles, and when we
asked colleagues to help cut them down, they simply
suggested more titles. The list got much longer for the
second and third editions. It was a long and painful
process to make the selections.
In the end, we selected the readings with five cri-
teria in mind:
n Readability: reading levels appropriate for upper-
division undergraduates who have already taken
a basic anthropology course
n Diversity: a mix of classic articles and more recent
contributions
n Different theories: a range of orientations
n Level of difficulty: a range of theoretical difficulty
or sophistication
n Ethnographic variation
Many selections are from the standard professional
journals in the field, including Medical Anthropology
Quarterly; Medical Anthropology; Social Science and Med-
icine; Human Organization; Anthropology and Medicine;
and Culture, Medicine, and Psychiatry.
To add to the pedagogical value of this collection,
we have included section and reading introductions.
In section introductions, we emphasize the “concep-
tual tools” that are put to work in each kind of medi-
cal anthropology. Students should be reminded of the
central concepts before they start reading the details
of a particular case. In selection introductions, we
describe the context for the problem at hand by rais-
ing related issues and by listing some questions for
discussion. Most introductions and conceptual tools
sections include bibliographic suggestions for further
reading, which are listed at the back of the book. These
references may be useful for undergraduates who are
writing term papers or for graduate students who are
developing a stronger grasp of the field. There are,
of course, a great many other resources in medical
anthropology, many of which are available through
the Society for Medical Anthropology.
We are painfully aware that, owing to space
constraints, many important topics in medical
anthropology are not represented here, including eth-
nopharmacology, health policy, childbirth, gerontol-
ogy, embodiment, phenomenology, and specific clini-
cal cases. We hope that instructors using this book feel
free to contact us with their opinions about selections
that work (or do not work) and with suggestions for
future editions.
NEW TO THE THIRD EDITION
One of the main challenges in revising this reader has
been to update it without completely changing a text
that has been warmly received. The combination of
newer articles and “classics” was designed for maxi-
mum pedagogical benefit. We believe that the new
selections are great vehicles for teaching and encour-
aging class discussion. Many new articles are original
to this reader, written with an undergraduate audi-
ence in mind. We think that these new chapters—writ-
ten by many of the field’s leaders, including a number
of Margaret Mead Award winners—convey clearly to
undergraduates the current vitality and relevance of
medical anthropology.
We have reorganized the section and subsection
headings to fit current themes in medical anthro-
pology. In addition to section and article introduc-
tions—with thought questions for your students—a
context box appears at the end of the introduction
to each selection; these short pieces are intended
for more advanced students interested in knowing
where the articles fit within the intellectual history
of medical anthropology—and they often describe
the author’s larger research agenda and discuss why
this particular article was written. This background
information can help students to appreciate the read-
ing more fully. (The article’s original source citation,
when applicable, appears on the bottom of the chap-
ter-opening page, along with the book’s copyright
statement.)
Over the years we have heard positive feedback
about the conceptual tools introduction, especially from
students. Therefore, we have updated and expanded
these bullet points where appropriate.
To the Student
What initially sparked your interest in medi-
cal anthropology? The prospect of studying other
medical systems, such as shamanism? The thought
of discovering what made disease rates increase in
ancient societies? Your concern about the serious
health problems in the United States and through-
out the world? An interest in how people are affected
by chronic disease, or in the culture of Biomedicine?
All these topics—exotic and mundane—are related
to medical anthropology. Or maybe your interest is
related to your career ambitions or current work in
the health care field. Whatever the case, you will find
the study of medical anthropology to be intriguing
and intellectually rewarding.
We also hope that you find the study of medi-
cal anthropology to be relevant to your life—if only
because disease, illness, healing, and death are uni-
versal in the human experience. All cultures have
medical systems. Whether you participate in a medi-
cal system as a patient or a healer, there is real value
in understanding the big picture of how and why that
system works. But, as the title of this book suggests,
you first need to understand medical anthropology
before you use it to make a difference in the world.
As you skim through this book, notice the
extremely wide variety of topics included within
medical anthropology. This diversity is based on the
broad, holistic approach that anthropology takes to
the study of human biology and cultures. In the United
States, anthropology traditionally includes four fields;
biological or physical anthropology, archaeology, cul-
tural anthropology, and anthropological linguistics.
Medical anthropology is not one of the four fields;
rather, it involves the use of anthropological concepts
and methods from all four fields in the study of health,
disease, and healing. One of the hallmarks of medical
anthropology, therefore, is the theoretical and practi-
cal diversity within the field.
Most medical anthropologists, like most anthro-
pologists in general, concentrate on the cultural end
of the field. Many courses in medical anthropology
do not deal with evolutionary or biological questions.
Your course instructor will likely pick and choose
selections according to his or her orientation to the
field. That is as it should be, but we hope that you
will also see this book as a resource for independently
exploring other approaches.
We have selected the readings with you, the stu-
dent, in mind. Primarily, we picked selections that
contain interesting case studies or that are controver-
sial and might help to spark class discussions. But
we also wanted the selections to reflect diversity—in
terms of both sophistication and the areas of the world
represented. Some readings are classics in the field
written by famous anthropologists. Although these
articles may be older, they usually make for wonder-
ful reading. Most of the articles are from professional
scholarly publications (for example, Medical Anthro-
pology Quarterly; Medical Anthropology;
Social Science and Medicine; Culture, Medicine, and
Psychiatry; and Anthropology and Medicine), and they
will, on occasion, require concentrated reading on
your part. You may want to skim the article first to
familiarize yourself with the overall structure of the
argument. “Prereading” for the main ideas is not a
substitute for the real reading, but it can prepare you
to understand the article when you do read it.
In the introductions we have provided orientations
to the general context and framework of the material.
Section introductions provide important “conceptual
tools”; put these concepts and vocabulary tools into
your own personal intellectual toolbox and “own”
them. Each selection introduction also includes ques-
tions to ponder. These questions will help you to place
a particular selection into the larger scheme of things,
to get you to think about the broader (and sometimes
unanswerable) questions involved. At the end of each
introduction, you will find a “context box” that will
tell you something about the selection’s author and
why the article was written.
Because medical anthropology is such a diverse
field, we have divided this book into two main parts.
Part I introduces you to the multiple approaches used
by medical anthropologists in their research and other
work. Part II is about applying medical anthropology.
This part covers a variety of different problem areas—
from doctor-patient communication to global health
programs—and presents selections that illustrate how
anthropological analysis can be relevant to under-
standing and solving those real problems.
10 To the Student
Note that there is an important field called “applied
anthropology” in which people, including medical
anthropologists, do research, program implementa-
tion, and program evaluation for particular clients who
hire them to work on particular problems. The writings
of these applied anthropologists are often in reports for
their clients. The selections in Part II do not all fit neatly
within the domain of applied anthropology. Although
many discuss particular solutions to a problem—
such as the AIDS epidemic or social stigma related
to disease—the main purpose of other selections is
to get readers to rethink the problem in a new way.
This rethinking is what is meant by “applying” medi-
cal anthropology (Podolefsky, Brown, and Lacy 2011).
If you are interested in learning more about
medical anthropology, you may want to consult one
of its handbooks. They include the classic collection
by Sargent and Johnson, Medical Anthropology: Con-
temporary Theory and Method (1996), the two-volume
Encyclopedia of Medical Anthropology by Ember and
Ember (2004), and A Companion to Medical Anthropol-
ogy by Singer and Erickson (2011). If you are thinking
about graduate study, you may want to consult the
website of the Society for Medical Anthropology
(www.medanthro.net). The major academic journals
in the field include Medical Anthropology Quarterly;
Medical Anthropology; Social Science and Medicine;
Culture, Medicine, and Psychiatry; and Medicine and
Anthropology.
We hope you enjoy the selections here and that
you learn a lot from your study of medical anthro-
pology. What you learn in this course will encourage
you to think more broadly about disease, healing,
illness experiences, and medical systems at home and
around the world.
Peter J. Brown and Svea Closser
September 2015
Part I
UNDERSTANDING MEDICAL ANTHROPOLOGY
Biosocial and Cultural Approaches
Page Intentionally Left Blank
 1
Medical Anthropology: An Introduction
Peter J. Brown
Svea Closser

Chances are you just started taking this course in medi- paradigm or model. For example, medical anthropology is
cal anthropology, and you are not sure what exactly it not limited to the study of exotic, non-Western medical sys-
is going to be about. Chances are also that one of your tems, even though the description of religion and healing
friends—or your roommate or even your parents—will systems is as old as anthropology itself. The field now also
ask: “Sounds interesting, but what is medical anthropol- has other areas of research, such as the cultural analysis of
ogy?” The purpose of this selection is to help you to be pre- biomedicine and the understanding of the globalization of
pared to answer that question. As you will see, it is not an biomedical technologies.
easy one to answer. Many medical anthropologists have As you read this selection, consider these questions:
this problem, for example, at cocktail parties. Part of the
problem is that many people—even well-educated ones— n What do anthropologists mean by culture, and
do not really know what anthropology is. Therefore, when how is it related to health and healing?
some people ask the question, they have a preconception n Why is the distinction between disease and ill-
that anthropology means only archaeology. In this situa- ness important in medical anthropology? Why
tion, your challenge is to gently help them out by saying might this difference not be very important to
something like this: “Although some medical anthropolo- physicians and other health care providers?
gists do study the health of prehistoric populations, most
n Which of the different approaches in medical
medical anthropologists use a cultural orientation to study
anthropology seems most interesting to you?
health and medicine in contemporary populations, espe-
Why?
cially multiethnic ones like our own.” But long definitions
are not always useful. Therefore, to keep the conversation
interesting, have a few examples of medical anthropologi-
cal research at hand. Chapter 1’s selection provides some
Context: The following article, updated by Peter
interesting ones.
Brown and Svea Closser, was originally provided
Medical anthropology studies human health prob-
for this reader by Ron Barrett, Mark Padilla, and
lems and healing systems in their broad social and cul-
Erin Finley. Peter Brown is a professor of anthro-
tural contexts. Medical anthropologists engage in both
pology and global health at Emory University;
basic research on issues of health and healing systems
Svea Closser is an associate professor of anthropol-
and applied research aimed at improving therapeutic care
ogy and global health at Middlebury College. In
in clinical settings or improving public health programs
the years since the first (much different!) version of
in community settings. Drawing from biological, social,
this article was written, medical anthropology has
and clinical sciences, medical anthropologists engage in
grown exponentially, developing into a rich and
academic and applied research, contributing to the under-
varied field. It is a measure of the field’s diversity
standing and improvement of human health and health
and ongoing evolution that not all medical anthro-
services worldwide.
pologists will agree with the structure of the disci-
Medical anthropology is inherently interdisciplinary—
pline as it is presented here.
meaning that it is not characterized by a single theoretical

Understanding and Applying Medical Anthropology: Biosocial and Cultural Approaches (3rd ed.) by Peter J. Brown and Svea Closser, 13–24 © 2016
Taylor & Francis. All rights reserved. Chapter 1 original article source: P. J. Brown and S. Closser. 2015. Medical Anthropology: An Intro-
duction to the Fields. In P. J. Brown and S. Closser (Eds.), Understanding and Applying Medical Anthropology (3rd ed.).

13
14 Part I—Understanding Medical Anthropology: Biosocial and Cultural Approaches
WHAT IS MEDICAL ANTHROPOLOGY?
M
edical anthropology is the application of anthropo-
logical theories and methods to questions of health,
illness, medicine, and healing.
The Society for Medical Anthropology uses a
more lengthy definition:
Medical Anthropology is a subfield of anthropology
that draws upon social, cultural, biological, and lin-
guistic anthropology to better understand those fac-
tors which influence health and well-being (broadly
defined), the experience and distribution of illness,
the prevention and treatment of sickness, healing pro-
cesses, the social relations of therapy management, and
the cultural importance and utilization of pluralistic
medical systems. The discipline of medical anthropol-
ogy draws upon many different theoretical approaches.
It is as attentive to popular health culture as bioscientific
epidemiology, and the social construction of knowl-
edge and politics of science as scientific discovery and
hypothesis testing. Medical anthropologists examine
how the health of individuals, larger social formations,
and the environment are affected by interrelationships
between humans and other species; cultural norms and
social institutions; micro and macro politics; and forces
of globalization as each of these affects local worlds.
(Society for Medical Anthropology 2015)
This definition can be daunting to someone coming
to anthropology for the first time, but its essential
point is as we stated: Medical anthropology is the
anthropological study of health and healing. Medi-
cal anthropology takes the tools of anthropology and
applies them to human illness, suffering, disease,
and well-being.
To understand what medical anthropology is,
then, one must understand anthropology as a whole.
Introductory anthropology courses usually begin
with some variation of the short and classic definition:
“Anthropology is the study of humankind.” Although
a bit vague, this definition underscores that anthro-
pology is a holistic and interdisciplinary enterprise
that uses many different approaches to understand
important human issues. In the broadest sense, these
approaches are usually categorized into four major
subfields: cultural anthropology, physical or biologi-
cal anthropology, anthropological archaeology, and
anthropological linguistics.
These days, however, introductory courses are
often the first and last places where anyone gives much
thought to the relationships among these four sub-
fields of anthropology. In recent decades anthropol-
ogy has gone the way of many academic disciplines.
Its subfields have become increasingly specialized,
each with its own dictionaries and theoretical orien-
tations. As a result of these increasingly specialized
differences, the academic discussions between the
subfields of anthropology have gotten scarce. Such
trends are unfortunate, because the compartmentali-
zation of anthropology often undermines the disci-
pline’s greatest strengths: its holistic approach and
interdisciplinary nature.
Culture is, of course, a central concept in
anthropology—although its definition is contested.
One definition of culture is “the learned patterns
of thought and behavior shared by a social group.”
Culture includes not only belief systems but also the
economic systems and social structures that affect
how people live. Many selections in this book show
how culture has profound influences on health.
But because health is influenced not only by cul-
ture and social structure but also by evolution and
biology (and in fact we argue in this book that biol-
ogy and culture are inseparable), medical anthropolo-
gists often draw on more than one subdiscipline. For
example, some selections in this reader show how the
biology, growth, and development of human beings
are historically and currently shaped by cultural
influences. Human biology and culture are intimately
related, and so we should adopt a holistic perspective
when we are studying human health and sickness.
In regard to the four traditional subfields of
American anthropology (cultural anthropology,
physical or biological anthropology, anthropologi-
cal archaeology, and anthropological linguistics), the
most common type of anthropologist is a cultural
anthropologist. And most practicing medical anthro-
pologists were trained in cultural anthropology. But
medical anthropology, a relatively new area of spe-
cialization, is not really a subfield, partly because, as
we mentioned, subfields of anthropology generally
have a central theoretical paradigm. In contrast, medi-
cal anthropologists use a wide variety of theoretical
perspectives—and they often do not agree on which
ones are best. As you will see, medical anthropolo-
gists apply a range of theories and methods to issues
of human health, sickness, and healing.
BASIC CONCEPTS
As is the concept of culture, the notion of health is
difficult to define. According to the charter of the
World Health Organization, health is “a state of com-
plete physical, mental and social well-being, and not
merely the absence of disease or infirmity” (World
Health Organization 2015a).
What constitutes well-being in one society, how-
ever, may be quite different from another. The ideal
of a lean-figured body—a sign of health in the West—
may indicate sickness and malnutrition in sub-Saharan

Africa (Brown 1981). In the fishing villages that line
Lake Victoria, the parasitic disease schistosomiasis is
so prevalent that the bloody urine of young males is
considered a healthy sign of approaching manhood
(Desowitz 1987). In the United States, the “elegant pal-
lor” and “hectic flush” of consumption (tuberculosis)
were often imitated by healthy people at the turn of
the 20th century because of the disease’s association
with famous writers and artists (Sontag 1983). Any
conceptualization of health must therefore depend
on an understanding of how so-called normal states
of well-being are constructed within particular social,
cultural, and environmental contexts.
Core Concepts
Medical anthropologists use two terms to talk about
states of ill health: illness and disease. Disease refers to
the clinical manifestations of altered physical function
or infection. It is a clinical phenomenon, defined by
pathophysiology. Illness, in contrast, encompasses the
human experience and perceptions of alterations in
health, as informed by its broader social and cultural
dimensions.
This distinction helps in understanding many
important phenomena, such as interactions between
patients and healers. For example, a doctor using a
disease model may see the patient’s symptoms as
the expression of clinical pathology, a mechanical
alteration in bodily processes that can be “fixed” by a
prescribed biomedical treatment. From the patient’s
perspective, however, an illness experience may
include social as well as physiological processes. The
physician’s diagnosis may not make sense in terms
of the patient’s understanding of her illness, and the
doctor’s “cure” may not take into consideration the
patient’s family dynamics, the potential for social
stigma in the community, or lack of money to follow
through with treatment.
Healing practices that humans use range from
cardiac bypass surgery, to amulets worn for protec-
tion against the evil eye, to conflict resolution between
kin groups. Shamans, priests, university-trained phy-
sicians, and members of one’s family may assume a
healing role at any given time in a person’s life. All of
these, including biomedicine, are aspects of ethnomedi-
cines, medical systems firmly tied to cultural systems.
A Critical Perspective
In the last part of the 20th century, medical anthropol-
ogy experienced a significant break from its past. Dur-
ing this period, there were intense intellectual debates
1 Medical Anthropology: An Introduction 15
about the approaches sometimes called critical theories,
including postmodernism and Marxism. In general,
these approaches require people to critically exam-
ine their own intellectual assumptions about how the
world works; the basic idea is that our ideas of reality
are shaped by our culture and that sometimes these
ideologies conceal complex political relationships.
These debates influenced cultural anthropology
in general and medical anthropology specifically. An
important outcome was the development of critical
medical anthropology, a perspective that coalesced in
the 1980s and 1990s (Singer 1989). These days, the per-
spectives of critical medical anthropology are main-
stream within medical anthropology. Most medical
anthropologists agree with two broad critiques that
critical medical anthropology made of earlier work.
The first critique was that many medical anthro-
pologists had incorrectly attributed health disparities
to cultural differences without examining the influ-
ence of global political-economic inequality on dis-
ease distribution. In the past, medical anthropologists
had tended to view illness as existing within local
cultural systems, and they neglected the larger politi-
cal and economic context within which these cultures
are found. Critical medical anthropologists described
how large-scale political, economic, and cognitive
structures constrain individuals’ decisions, shape
their social behavior, and affect their risk for disease.
Readings in this book that exemplify this approach
are in Chapter 11 by Paul Farmer and Chapter 14 by
Merrill Singer.
One example of this kind of thinking was
Meredeth Turshen’s analysis of the political-economic
dimensions of disease in Tanzania. Turshen described
how a history of colonialism drastically affected
the country’s nutritional base, altered its kinship
structure, and imposed constraints on its health
care system. She questioned previous studies’ focus
on local culture and emphasized an alternative she
called the “unnatural history of disease” (Turshen
1984). Critical medical anthropologists made similar
arguments concerning health disparities in wealthier
countries like the United States.
Because of their interest in macro-level forces
(such as world capitalism), critical medical anthro-
pologists were generally skeptical of health policies
that proposed local solutions. Thus critical medical
anthropologists not only challenged the local focus of
traditional medical anthropology but also criticized
the narrow focus of health interventions that did not
address the large-scale factors influencing disease
(Morsy 1990).
The second critique made by critical medical
anthropology centered on the questioning of underly-
ing epistemologies (ways of knowing) and conceptual
16 Part I—Understanding Medical Anthropology: Biosocial and Cultural Approaches
categories of medicine and Western culture in general.
For example, the 16th-century French mathematician,
scientist, and philosopher René Descartes articulated
a fundamental cultural model of the separation of
mind and body. This is a “culturally constructed”
idea that many people take for granted in everyday
thought and talk. But your own experiences of emo-
tional states—not to mention recent discoveries in
neuroscience—make it clear that the body/mind dis-
tinction is not quite true. Similarly, there are many
notions embedded in everyday clinical medicine that
are culturally constructed and often based on meta-
phors. For example, low blood pressure is consid-
ered a dangerous sign of heart problems in Germany,
while in the United States it is considered a marker of
excellent health (Payer 1988). The ideas and practice of
medicine cannot be separated from culture.
From our perspective, the mainstreaming of the
critical perspective within medical anthropology has
led to many important developments, including an
energetic engagement with social justice and health
disparities. Paul Farmer, a physician and anthropolo-
gist who also directs the nonprofit organization Part-
ners in Health, has been highly influential in this area.
Farmer’s most famous work highlights the impact of
global inequality on the emergence of such infectious
diseases as HIV/AIDS and multidrug resistant tuber-
culosis (Farmer 1999, 2004). In providing a critical
perspective on global inequalities in health, Farmer
and many others have effectively highlighted how
socioeconomic and political factors cause profound
inequalities in health and disease.
A Practice Orientation
Medical anthropologists engage in research on issues
of health and healing systems, as well as research
aimed at the improvement of therapeutic care and
public health programs. Sometimes these types of
research are labeled as “basic” or “applied,” respec-
tively, but because medical anthropologists study
human health, most “basic” research has obvious
practical relevance, and many of the field’s core the-
oretical concepts were developed by people actively
engaged in clinical and public health work. There is
a great deal that we do not know about the causes of
sickness and the processes of healing; anthropologists
can contribute to the growth of human knowledge in
these important areas. At the same time, anthropolo-
gists contribute to the design and implementation of
programs alleviating complex health problems. This
back-and-forth between engagement and reflection
energizes the discipline.
Many medical anthropologists, then, have a
practice orientation (Inhorn and Wentzell 2012), even
as they think theoretically. Unlike other social scien-
tists, medical anthropologists generally think they
have an obligation to act to improve human health
(Fassin 2012). This belief, however, doesn’t mean
that they agree on what action is appropriate. Medi-
cal anthropologists’ critical perspectives indicate that
they are very aware that the institutional structures
of biomedicine and public health sometimes entrench
inequalities rather than alleviate them. Most medical
anthropologists are constantly reflecting on whose
interests their involvement in these structures serves
(Singer 1995).
Some medical anthropologists are very actively
engaged within biomedical and public health institu-
tions. For a significant period of its history, medical
anthropology dealt with the health beliefs and prac-
tices of ethnic minorities. Margaret Clark’s Health in
the Mexican-American Culture (1959) is a good exam-
ple of such work. Her analysis emphasizes, for exam-
ple, that it is insufficient simply to translate medical
instructions when the patient population has limited
literacy and biomedical language (in any language)
is unfamiliar to them. Medical anthropologists have
often been called to assist in improving communi-
cation across both language and cultural barriers
between patients and their health care providers. Such
problems in communication have been described
in Anne Fadiman’s book The Spirit Catches You and
You Fall Down (1998), which deals with the conflicts
between the family of a Hmong child and her Ameri-
can doctors. Some perspectives on “cultural compe-
tency” training programs in medical schools can be
found in Part II in the section titled “Working with the
Culture of Biomedicine.”
Not all anthropologists agree that these training
programs are a good thing. Several medical anthropol-
ogists have argued that such programs reinforce racial
stereotypes rather than dealing with power inequities
that are at the root of poor health outcomes (Carpenter-
Song, Schwallie, and Longhofer 2007; Gregg and Saha
2006). Such active debate and reflection—both engaged
with and critical of practice—is a hallmark of medi-
cal anthropology. A critical analysis of such a cultural
competency course at Harvard Medical School can be
found in the selection in Chapter 35.
Anthropologists working within clinical settings,
however, do much more than talk about culture and
communication. Anthropologists within the Veterans’
Administration (VA), for example, work on a variety
of issues, including the root causes of substance abuse
and homelessness in female veterans (Cheny et al.
2013; Hamilton, Washington, and Zuchowski 2013)

and the improvement of mental health services for
veterans with posttraumatic stress disorder (PTSD)
(Besterman-Dahan, Lind, and Crocker 2013; Finley
2013).
In addition to clinical settings, many anthropolo-
gists work in public health policymaking, program
development, and intervention. Anthropological per-
spectives are relevant at all levels of the public health
process, from the interpretation of disease trends to
the design, implementation, and evaluation of pro-
grams. For example, medical anthropologists working
on the Ebola response did research on topics from the
role of informal health workers in the Ebola response
to the long-term investments needed for stronger
health systems and the reasons why some people
might resist interventions aimed at stopping Ebola
(Ebola Response Anthropology Platform 2015). They
also argued compellingly in international venues that
public health agencies should stop conceptualizing
culture as a barrier and a source of misinformation
and should instead focus on designing responses the
desires and needs of recipient populations in mind
(Chandler et al. 2015).
Yet other medical anthropologists think that ana-
lyzing and writing, often from within the academy, is
the best way to create positive change. These medi-
cal anthropologists believe that it’s hard to think and
write critically about health institutions if one is too
close to them (or working for them), so they advocate
speaking truth to power from outside such structures,
often from academic positions.
Through work both practical and theoretical,
medical anthropologists contribute to our under-
standing of issues with life-and-death consequences.
They approach these issues from a wide variety of
theoretical perspectives, all rooted in anthropology.
FIVE BASIC APPROACHES TO
MEDICAL ANTHROPOLOGY
The scope of anthropological inquiry into issues of
human health, sickness, and healing is very diverse—
so diverse in 2015 that writing this introduction,
which characterizes the field, is intimidating. None-
theless, we’ve identified five basic approaches to med-
ical anthropology:
1. biological
2. ecological
3. ethnomedical
4. experience-near
5. studies in and of biomedicine.
1 Medical Anthropology: An Introduction 17
The first two of these approaches emphasize the inter-
action of humans and their environment in a way
that we consider biosocial—that is, with a focus on
the interaction between biological/health questions
and socioeconomic and demographic factors. The last
three of these approaches to medical anthropology are
cultural—they emphasize the concept of culture (the
patterns of thought and behavior characteristic of a
group) and how people experience life.
For all the diversity of the field, nearly all medical
anthropologists share four essential premises: (1) that
illness and healing are best understood in the com-
plex and varied interactions between human biology
and culture; (2) that disease is influenced by culture,
economics, and politics; (3) that the human body and
symptoms are interpreted through cultural filters;
and (4) that the insights of medical anthropology have
important pragmatic consequences for the improve-
ment of health and health care in human societies.
1. Biological Approaches in Medical
Anthropology
Much research in biological anthropology concerns
important issues of human health and illness. Many
of the contributions of biological anthropologists help
to explain the relationships between evolutionary
processes, human genetic variation, and the differ-
ent ways that humans are sometimes susceptible, and
other times resistant, to disease.
The evolution of disease in ancient human popu-
lations helps us to better understand current health
trends, a concept described in more detail in Chapter
8’s selection by George Armelagos, Peter Brown, and
Beth Turner. For example, the recent global trend of
emerging and reemerging infectious diseases, such
as tuberculosis and AIDS, is influenced by forces of
natural and cultural selection that have been pre-
sent throughout modern human evolution. During
the time of the Paleolithic (about 2,500,000 to 200,000
years ago), early human populations lived in small
bands as nomadic hunters and gatherers. The low
population densities during this period would not
have supported the acute infectious diseases found
today; instead, chronic parasitic and insect-transmitted
diseases were more prevalent.
The shift toward sedentary living patterns and
subsistence based on plant and animal domestication,
sometimes called the Neolithic Revolution (about
10,000 b.c.e.), had a profound effect on human health.
Skeletal evidence from populations undergoing this
transition shows an overall deterioration in health con-
sistent with the known relationship between infectious
18 Part I—Understanding Medical Anthropology: Biosocial and Cultural Approaches
disease and malnutrition. New infectious diseases
emerged, a result of increasing population density,
social stratification, decreased nutritional variety, prob-
lems of clean water and sanitation, and close contact
with domesticated animals (Armelagos, Goodman,
and Jacobs 1991; Cockburn 1964). These changes had
a disproportionate effect on women, young children,
the elderly, and the emerging underclass, who were
most susceptible to infections in socially stratified
societies (Armelagos and Cohen 1984).
Currently, great threats to human health come
from chronic degenerative conditions. These so-
called diseases of civilization, such as heart disease,
diabetes, and cancer, are the leading causes of adult
mortality throughout the world today. Many of these
diseases share common etiological (causative) fac-
tors related to human adaptation over the last 100,000
years. For example, obesity and high consumption of
refined carbohydrates and fats are related to increased
incidences of heart disease and diabetes. Human sus-
ceptibility to excess amounts of these substances can
be explained by the evolution of human metabolism
over millions of years in contexts of relatively large
amounts of exercise, seasonal food shortages, and
diets low in fat (Konner and Eaton 2010; Weil 2008).
A related theory of “thrifty genes” was pro-
posed to explain relatively shorter-term evolution-
ary changes that account for genetic variation in the
susceptibility to chronic diseases between different
contemporary populations (Neel 1982). Some popula-
tions have significantly higher prevalences of adult-
onset diabetes and hypertension than others. The
thrifty-gene hypothesis proposes that genes affecting
insulin physiology were selected for, allowing people
to adapt to an irregular food supply. This adapta-
tion arose during times of “feast or famine” for cer-
tain populations, including some Native Americans,
oceangoing Pacific Islanders, and African Americans
descended from slaves. In the context of modern diets,
however, these genes add to the burden of chronic
disease (Lieberman 2008).
But variation in human susceptibility to chronic
diseases cannot be accounted for by genetic explana-
tions. Environmental and sociocultural factors play
a primary role. Health disparities between ethnic
groups in the United States are a result of discrimi-
nation leading to poorer living environments and
increased stress, among other causes of poor health
(Dressler 1996; Williams 1999).
Some biological contributions to medical anthro-
pology critique the misapplication of biological con-
cepts. During the late 19th century, measurements
of cranial size were taken of Jewish and Southern
European immigrants to the United States and com-
pared with those of Anglo-American residents. The
differences in cranial size between these populations
were used to support a theory of racial hierarchy based
on hereditary differences in brain size. By careful com-
parisons between first- and second- generation groups
from these immigrant populations, Franz Boas (the
founder of American Anthropology) was able to dem-
onstrate that these differences were attributable to
environmental influences on body size (Boas 1940).
Subsequent analyses have discredited previous stud-
ies relating measurements of intelligence to those
of cranial capacity (Gould 1981), and categories of
human races have been shown to have little validity
in the study of human variation (Goodman, Moses,
and Jones 2012).
Some biological anthropologists also contribute
to the field of ethnopharmacology. Anthropologists
in this field consider not only the physiological prop-
erties of plant substances but also issues related to
their selection, preparation, and intended uses within
particular social settings and broader cultural frame-
works (Etkin 1996).
Biological anthropology plays a central role in
the field of evolutionary medicine, which considers
how survival pressures over the course of evolution
may have shaped human biology. Health research-
ers who incorporate an appreciation of the ongoing
effects of natural selection on the physiology of peo-
ple and other organisms may be equipped to develop
more sophisticated approaches in their efforts to
treat or prevent disease (Nesse and Williams 1996).
For example, research on SIDS (sudden infant death
syndrome) and children’s sleeping arrangements has
shown that despite statements by many officials in the
United States that infants should always sleep alone,
mother-infant cosleeping (the evolutionary norm)
may be the safest choice for babies in particular social
and economic contexts (McKenna and McDade 2005).
Biological anthropology’s appreciation for the inter-
connectedness between genes and environment has
led to many developments in the field of evolution-
ary medicine and holds promise for many more. The
reading selection in Chapter 3 deals with this topic.
2. Ecological Approaches
Ecology refers to the relationships between organisms
and their total environment. Within medical anthro-
pology, the ecological perspective focuses on the inter-
actions between environmental contexts and human
health. An ecological approach to medical anthro-
pology emphasizes that the total environment of the
human species includes the products of large-scale
human activity, as well as “natural” phenomena, and
that health is affected by all aspects of human ecology.

It includes attention to how people survive in varying
environments, how they find food, how they distrib-
ute resources, how they deal with disease, and how
the demographics of their population are changing
over time (McElroy and Townsend 2014). Pathogens
that cause infectious disease, such as the malaria par-
asite, and factors that affect risk for chronic disease,
for example, diet, are closely tied to humans’ relation-
ships with their environments. The term medical ecol-
ogy has been used to describe this approach.
Two broad levels of analysis inform this approach.
At the micro level, cultural ecology examines how cul-
tural beliefs and practices shape human behavior,
such as sexuality and residence patterns, which in
turn alter ecological relationships between host and
pathogen. At a broader level, political ecology exam-
ines the historical interactions of human groups and
the effects of political conflict, migration, and global
resource inequality on disease ecology (Brown, Smith,
and Inhorn 1996). Many ecological approaches to
medical anthropology include some aspects of both
cultural and political ecology. Malaria and schistoso-
miasis provide two useful examples.
Malaria is a disease caused by a microscopic
Plasmodium parasite that is transmitted to human
hosts through contact with mosquitoes of the genus
Anopheles. These mosquitoes breed and multiply in
stagnant pools of water in warm climatic regions of
the world. Malaria has a long and sordid history in
many societies, and it continues to be a major cause of
human morbidity and mortality today (Brown 1997).
At a cultural ecological level, adaptations to malaria
include highland Vietnamese building practices, in
which stilted houses allowed people to live above the
10-feet mosquito flight ceiling (May 1958). In another
ecological context, although malaria had been eradi-
cated in the southern Italian island of Sardinia, Brown
discovered that many cultural practices functioned
to reduce contact with malaria-carrying mosquitoes
(Brown 1981;) see the selection in Chapter 7). These
included settlement and land-use patterns, whereby
nucleated villages are located in highland areas and
flocks of sheep are taken to the lowlands in the winter,
thus minimizing contact with the mosquitoes during
peak malaria seasons.
At a political ecological level, however, these
adaptive cultural practices were probably motivated
by historical threats of military raids and expropria-
tion of land by foreigners. Furthermore, wealthy
Sardinians had less contact with mosquitoes because
they did not have to leave the safety of the village to
work in the fields as did the laborers, nor did they
have to stay in the village during peak malaria sea-
son when they could afford to take summer vacations
abroad. Thus, the example of malaria demonstrates
1 Medical Anthropology: An Introduction 19
that multiple ecological variables—biological, cul-
tural, political, and economic—interact to influence
the prevalence of particular diseases in a given envi-
ronmental context. In recent years—marked by the
advent of climate change—more areas of the world
have become vulnerable to malaria; this is a political
ecological phenomenon.
Schistosomiasis, a parasitic disease spread by
snails, provides a dramatic example of the relation-
ship between political ecology and disease. For dec-
ades, economic development programs throughout the
world have often focused on the building of dams to
prevent seasonal flooding, improve irrigation, and pro-
vide hydroelectric power (Heyneman 1979). Enormous
dams, such as the Aswan High Dam on the Nile River,
have dramatically altered the ecology of surrounding
areas by preventing seasonal flooding and creating one
of the largest man-made bodies of water in the world.
A byproduct of such changes, however, is an altered
relationship between human populations and certain
water-borne parasitic infections, such as schistosomia-
sis. The small snails that carry schistosomiasis thrive
in the numerous irrigation canals emanating from the
dams, increasing human exposure to the parasites. This
exposure has led to an increased risk of contracting
schistosomiasis, an infection that primarily affects chil-
dren, in people that live close to some kinds of dams
and irrigation systems. But the way this relationship
plays out depends on the larger ecological context of
the dam, as well as the socioeconomic status of people
at risk (Steinmann et al. 2006).
The story of schistosomiasis demonstrates that
political-economic forces, such as dam development
programs, can dramatically shape the relationship
between host and disease in human populations.
Thus, medical ecology’s definition of “environment”
includes the political-economic consequences of col-
lective human activity. In this globalizing world
characterized by out-of-control carbon emissions and
climate change that will have serious health effects
(Chapter 10), there is no doubt that political-economic
policies directly influence local disease ecologies.
3. Ethnomedical Approaches
All societies have medical systems that provide a
theory of disease etiology (causation), methods for the
diagnosis of illness, and prescriptions and practices for
curative or palliative (calming, soothing) treatment. The
initial development of medical anthropology derived
from anthropological interest in the healing beliefs and
practices of different cultures (Wellin 1978). These
beliefs and practices related to healing are often referred
to as ethnomedicine. Anthropological approaches to the
20 Part I—Understanding Medical Anthropology: Biosocial and Cultural Approaches
study of ethnomedicine have always included not
only understanding how people think about health
and disease but also studying the social organization
of healing practices (Fabrega 1975). In the simplest
sense, all ethnomedical systems have three interre-
lated parts:
1. a theory of the etiology of sickness
2. a method of diagnosis based on the etiological
theory
3. the prescription of appropriate therapies based on
the diagnosis.
Health systems, from a cross-cultural perspective,
generally fall into two categories:
1. personalistic systems that explain sickness as the
result of supernatural forces directed at a patient,
by either a sorcerer or an angry spirit
2. naturalistic systems that explain sickness in terms
of natural forces, such as the germ theory of con-
tagion in Western biomedicine and the imbalance
of humours in many forms of Chinese, Indian,
and Mediterranean systems (see the selection in
Chapter 16).
At the beginning of the 20th century, anthropo-
logical studies of medical systems were confined to
ethnographic descriptions of “exotic” practices within
non-Western societies. Many of the observations
about sickness and therapeutic rituals were analyzed
as a window on underlying cosmological beliefs and
cultural values within comparative studies of myth
and religion. Some aspects of these works have been
criticized for a tendency to sensationalize the differ-
ences of “primitive” people in comparison to their
readership in Western industrialized societies (Rubel
and Hass 1996).
The term ethnomedicine was first defined as
“beliefs and practices related to disease which are the
products of indigenous cultural development and are
not explicitly derived from the conceptual framework
of modern medicine” (Rubel and Hass 1996). In recent
decades this arbitrary distinction supposedly “indig-
enous,” “traditional,” and “nonscientific” medical
systems and supposedly “Western,” “modern,” and
“scientific” medical systems has been abandoned by
nearly all medical anthropologists. Medical anthro-
pologists challenge the idea that biomedicine is an
empirical, law-governed science unbiased by cultural
premises. They understand that all medical systems
are constantly changing, and all are closely tied to
their cultural contexts.
In India, for example, many Ayurvedic practition-
ers receive university training, practice in commercial
institutions, and supplement their ancient therapies
with antibiotics, X-rays, and other tools of biomedi-
cine (Nichter and Nichter 1996). Likewise, many
Indian physicians trained in biomedicine use Indian
categories to explain health issues to their patients.
As another example, in her comparison of biomedi-
cal systems in Europe and North America, Lynn Payer
found considerable variability in the health beliefs
and practices that constitute biomedicine (Payer
1988). Because of these issues of cultural diversity
even within biomedicine, it is more useful to consider
ethnomedicine as the study of any form of medicine
as a cultural system. In other words, biomedicine is
one of many ethnomedical systems.
Patients often draw on the ideas of one or more
ethnomedical systems in their own understanding of
illness. They develop an explanatory model (EM), a
personal interpretation of the etiology, treatment, and
outcome of sickness by which a person gives meaning
to his or her condition. Although EMs are personal,
they are also learned cultural models, so that an EM
shared by a group might be considered a folk model of
disease. There is often disparity between the explana-
tory models of patients and healers, which may lead
to problems of communication and nonadherence to
prescribed therapies (Brown, Gregg, and Ballard 1997;
see the selection in Chapter 34).
While stated health beliefs may influence treat-
ment decisions, explanatory models alone are not
good predictors of people’s observed patterns of health
seeking—because significant differences often exist
between cultural “ideals” (what people say they do)
and “real” behavior of observable action. For example,
a study of Nepalese patients found that people often
sought multiple medical resources for a single illness
despite verbal claims to the contrary (Durkin-Longley
1984). Many different factors may weigh on decisions
concerning when and where to seek treatment, such as
the influence of family members (Janzen and Arkinstall
1982), social networks, and geographic access to health
resources (Kunitz 1989; Mumtaz et al. 2013). In many
cases, economic resources can severely limit treatment
options. Even with great strides made in lowering the
cost of antiretroviral therapy, for example, nearly two
thirds of HIV-positive people in low- and middle-
income countries do not have access to these lifesaving
drugs (World Health Organization 2015b).
4. Anthropology in and of Biomedicine
In recent years there has been an increased focus
on studying biomedicine as an ethnomedical sys-
tem of knowledge and social practice. Although this
approach has a lot in common with the study of other

ethnomedicines, it has become such a large part of the
subfield of medical anthropology that we are giving it
its own section here.
One classic example of this approach is an article
by Nancy Scheper-Hughes and Margaret Lock (1987).
They critically examined the idea that the mind and
body are separate entities, a fundamental premise of
biomedicine. They suggested that the dominance
of biomedicine had made the concept of separation
of mind and body so pervasive that people lacked a
precise vocabulary to express the complex interac-
tions between mind, body, and society.
The excellent text An Anthropology of Biomedicine
(Lock and Nguyen 2011) examines the “technologies
of the body in context,” including the human transfor-
mations (through transplants, and so on) that stretch
our moral boundaries. This focus includes an empha-
sis on biotechnologies such as genetic testing, the
use of pharmaceuticals, assisted reproduction, organ
transplants, genomics, plastic surgery, and other sci-
entifically derived treatments. In viewing how such
new technologies are taken up (or rejected) within
existing biomedical systems, we can observe how
they come to be associated with different social cir-
cumstances across different cultural settings. Repro-
ductive technologies such as in vitro fertilization, for
example, may come to epitomize one set of concerns
among women in the United States and a very differ-
ent set among men in Egypt and Lebanon. Chapter 27’s
article by Monir Moniruzzaman provides an example
of this kind of anthropological work.
The study of biomedicine sheds light on the epis-
temology of scientific and medical knowledge. Medi-
cal anthropologists study the processes by which
these forms of knowledge acquire their status as
“authoritative knowledge” rather than as “beliefs,”
the word often used to describe the knowledge sys-
tems of other ethnomedicines. As such, the distinction
between knowledge and belief can be seen as arbitrar-
ily reflecting differences in social power and therefore
as being highly questionable (Good 1994).
Studying the processes of knowledge creation in
biomedicine has provided important insight into how
“gold standards” of care and evidence come to be.
Medical anthropologist Allan Young, for example, has
shown how PTSD became accepted in the late 1970s
as a distinct mental illness (Young 1997). It was not a
process of psychiatrists suddenly discovering a new
disorder. Instead, PTSD came to be included in the
Diagnostic and Statistical Manual for Mental Disorders
(DSM), psychiatry’s official list of accepted diagnoses,
when a group of psychiatrists came together and—
urged by a vocal lobby of Vietnam veterans and their
advocates—agreed that PTSD should be recognized
despite a lack of medical and epidemiological research
1 Medical Anthropology: An Introduction 21
available to describe it. Chapter 31’s selection by Erin
Finley provides an excellent case study of PTSD in the
contemporary VA system.
Increasingly, medical anthropologists have exam-
ined the cultural and political dimensions of public
health and global health bureaucracies. Like scholars
who frame studies of biomedicine as a cultural sys-
tem, anthropologists are increasingly turning their
attention to the cultural beliefs, norms, and implicit
premises on which public health funding and admin-
istration are based (Biehl and Petryna 2013; Chandler
et al. 2015; Justice 1986). These medical anthropolo-
gists study a variety of public health agencies, from
UN agencies to NGOs to governments, and they pay
attention to the complex power relations between
these entities. Examples of this approach are in the
selections in Chapters 44 and 45, which explore the
contexts and complex effects of public health pro-
grams in Pakistan and Mozambique.
5. Experience-Near Approaches
In 1988, renowned anthropologist and psychiatrist
Arthur Kleinman published a book titled The Illness
Narratives, in which he advocated paying close atten-
tion to how people make sense of their illness experi-
ences through narrative (Kleinman 1988). He pointed
out that the stories people tell about their illnesses
can provide great insight into how they cope with
disease and suffering. Since then, what can broadly
be called an experiential approach in medical anthro-
pology has become increasingly resonant through-
out the other subfields. Anthropologists using this
approach frequently put illness-related suffering—
whether due to pain, disability, or the awareness of
one’s own mortality—at the center of their analysis.
They focus on three aspects of illness, in particular:
(1) narrative—the stories that people tell about their
illness; (2) experience—the way that people feel, per-
ceive, and live with illness; and (3) meaning—the
ways that people make sense of their illness, often
linking their experience to larger moral questions. For
example, in Chapter 23’s selection Linda Hunt con-
siders narratives from two individuals with cancer in
southern Mexico; although these two have different
cancers and face different life situations, both explain
their illness in relation to the disappointments and
obligations they have borne in their social lives.
Experiential (experience-near) approaches often
explore the links between sickness and problems in
the social world. Illness narratives in particular may
demonstrate how a symptom is experienced as trou-
bling because of its impact on relationships with oth-
ers, as when pain or fatigue interferes with a mother’s
22 Part I—Understanding Medical Anthropology: Biosocial and Cultural Approaches
ability to care for her children. Narratives may also
provide a venue for negotiating the meaning of an
illness, particularly in the social space between fam-
ily members, patients, healers, and so forth. Kohn
writes of how care providers treating children with
facial disfigurements in Northern California create
“therapeutic emplotments”—essentially, complex
narratives—that are intended to help the children to
feel more comfortable with their appearance. In try-
ing to transform the children’s narratives of them-
selves and their appearance, the care providers are
in fact trying to shift the children’s experience of
their disfigurement from one of embarrassment and
shame to one of acceptance and confidence (Kohn
2000). Narrative, then, is not just a story of what has
happened, or is happening, or might happen. It can
also represent an active attempt to negotiate or con-
struct both individual selfhood and social relations
amid sickness and suffering.
A central theme in ethnographic descriptions
of illness and suffering is stigma. People who are
different—either physically, mentally, or in social
skills—are often subjected to negative judgments and
discrimination from so-called normal people; that
is, they are stigmatized. The originator of this idea
in medical social science, Erving Goffman (1963),
referred to this type of social disapproval as creating
a “spoiled identity.” The archetype of a stigmatized
disease is leprosy (Hansen’s disease), which despite
its terrible reputation is not very contagious at all.
There are both visible and invisible conditions
that are stigmatized. With visible conditions, such as
being extremely short-statured, people end up being
stared at and ostracized; this situation is described
in Chapter 36’s selection by Joan Ablon. Invisible
conditions—for example, having depression or herpes,
or having had an abortion—are usually conditions
that people prefer to keep secret; disclosing such a
condition is difficult and often socially dangerous.
A great deal of medical anthropological research
has been done on HIV/AIDS since the beginning of
the pandemic. In some ways HIV/AIDS has been an
epidemic of discrimination and stigma; however, the
availability and antiretroviral drugs has changed this
slightly (see Chapter 45).
The experiential approach has been applied most
often in the exploration of illnesses that are highly
subjective, such as chronic pain and mental illness.
These experiences, internal as they are, may be dif-
ficult to share or explain. Medical anthropologists
attempt to understand conditions such as psychosis
from within, interacting closely with and listening to
those who might otherwise be ignored because of their
difficulties in behaving and expressing themselves in
normative ways (Desjarlais 1997; Jenkins and Barrett
2003). In addition to helping social scientists rethink
the cultural boundaries between what is considered
normal verses pathological, these studies have the
potential to explore the relationship between body
and mind in a more holistic way.
Anthropologist Joao Biehl, for instance, has traced
the paths by which ongoing socioeconomic changes
in Brazil, accompanied by an increasing medicaliza-
tion of illness and infirmity, have resulted in families
leaving their mentally and physically disabled mem-
bers to live in ragged communities on the margins of
society (Biehl 2013). Following this social progression
to its outcome at the level of individual experience, he
describes how mentally ill individuals in Brazil per-
ceive and make sense of this social abandonment.
The experience of illness is something that evolves
in the space between body and mind, and between
individuals and those in their social environment; it
may change over time as the disease progresses or
resolves. In understanding how illness is experienced,
medical anthropologists gain insight into how peo-
ple endure and make meaning in some of the most
vulnerable moments of their lives, and thus they can
better appreciate how these processes play out in peo-
ple’s explanatory models, care-seeking behaviors, and
coping strategies.
CONCLUSION
Medical anthropology, like its parent discipline, is a
holistic and interdisciplinary enterprise. We began this
chapter quoting the definition of this subfield offered
by the Society for Medical Anthropology. This defini-
tion includes so many topics covering such a diverse
set of questions that some readers may think that it
was written by a committee. In the simplest sense,
medical anthropology refers to studies of health and
healing from biosocial and cross-culturally compara-
tive perspectives. In this regard, healing refers to all
medical systems, including modern biomedicine and
its sophisticated technologies, as cultural products.
Because there is such a remarkable diversity of
theories and methods used in medical anthropology,
we can appropriately talk about it as having subdisci-
plines of its own. In this article, we have outlined five
major approaches that medical anthropologists use
to better understand issues of human health, healing,
and sickness: biological and ecological (biosocial), and
ethnomedical, experience-near, and studies in and of
biomedicine (cultural). When we explore the specific
examples, however, it becomes clear that the five cat-
egories overlap.

Part I of this book—the part devoted to under-
standing medical anthropology—contrasts biosocial
approaches and cultural approaches; this seems to
be a fundamental distinction. Yet on closer examina-
tion, even this simple distinction is artificial, because
the culturally oriented analyses focus on biological/
medical processes, and the biological approaches
almost always emphasize the role of human (cultural)
behavior. Within all this theoretical and methodologi-
cal diversity, there are essential commonalities in an
anthropological study of health, illness, and healing.
These commonalities all stem from an anthropologi-
cal view of the world.
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Biosocial Approaches in Medical Anthropology
Evolution and Human Biological Variation: Chapters 2–7
CONCEPTUAL TOOLS
n Evolution is the central theoretical concept in the
biological sciences, including anthropology. Evolu-
tionary theory is able to explain literally millions of
biological observations of the natural world. The fact
that scientists argue about specific cases or that there
are parts of the evolutionary record that we know lit-
tle about should not detract from our appreciation of
this important concept.
n A driving force determining the direction, char-
acter, and speed of evolutionary change is natural
selection. Evolutionary change depends on the inter-
action of organisms and their environment. That
interaction results in differential rates of morbid-
ity (sickness), mortality, and fertility for individuals
with different traits. Genetic evolution works when
there is variation in a population based on inherited
characteristics. In the process of natural selection
some inherited traits affect the ability of individuals
to survive and reproduce; thus, over generations of
individuals living and dying in a particular ecological
context, traits that enhance reproductive fitness tend
to increase. And genetic traits that make it more likely
that individuals or their offspring will have fewer off-
spring tend to decrease. Evolutionary change includes
the possibility that, over generations, a species can
change into another species. Geographic isolation can
accelerate this process.
n There are other forces in evolution besides natu-
ral selection. These include mutation, gene flow or
migration, and genetic drift.
n Variation can be genetic (in the genes) or pheno-
typic (in observable characteristics). Some biologi-
cal variation among contemporary humans is related
to health—either phenotypic variation is the result
of different health and nutritional experiences or
genotypic variation affects patterns of morbidity (the
state of being diseased) and mortality (the number
of people who died). Differences in stature (height),
for example, may reflect the adequacy of childhood
diet, whereas genetic differences are involved with
predispositions to a wide variety of diseases (Frisancho
1993).
In 2003, because of advances in molecular biol-
ogy, scientists sequenced the entire human genome.
This was an amazing feat, but it also highlighted how
much we do not know. Gene frequency differences
usually reflect historical forces of natural selection
or migration. Comparative studies of anthropologi-
cal genetics can help in reconstructing prehistoric
patterns of population movement—for example, the
movement of Siberian people to North America. Dif-
ference in gene frequencies among populations can
also reflect historical exposure to particular factors
in natural selection—including diseases and food
shortages.
Phenotype refers to expressed biological features
resulting from the interaction of genes and environ-
ment. People living for a long period at high eleva-
tions, for example, can physiologically adapt to the
shortage of oxygen by developing greater hemo-
globin density as well as greater lung capacity. Babies
born in higher altitudes tend to be smaller than babies
born at sea level. Probably the most important mech-
anism for phenotypic variation involves nutrition.
Biological anthropologists studying human growth
and development have shown that poor growth—
stunting and wasting—is a sensitive measure of lack
of adequate food in childhood. Other kinds of mal-
nutrition, such as deficiencies in the micronutrients
iodine and vitamin A, may have permanent effects
on mental capacity. Therefore, observed biological
variations among groups often reflect environmental
rather than genetic difference.
25
26 Part I—Understanding Medical Anthropology: Biosocial and Cultural Approaches
n Humans are unique in that we have a dual system
of inheritance—through both genes and culture—
and in that we largely depend on culture for survival.
Genetic evolution in humans follows the same rules as
in all living things. Cultural evolution, in contrast, is a
more flexible and potentially faster process. Cultural
systems change as people evaluate the influence of
their behavior in interaction with the environment.
Simply put, people tend to do things that improve
their conditions and avoid things that harm them or
make them sick. Cultural learning can be based on
borrowing ideas from nonkin, so that such learning
doesn’t take generations to occur. In many ways, cul-
tural evolution has outstripped biological evolution
for humans.
n Understanding the evolutionary strategies of
pathogens can be very useful for health care pro-
viders and people working in preventive medicine.
Evolution shapes the reproductive strategies used by
pathogens (microorganisms that can cause disease)
to pass their genes on to the next generation. When
health care workers and patients understand how
incomplete antibiotic treatment can result in “unnat-
ural selection” for resistant strains of bacteria, there
is more likelihood of patients’ adherence to correct
medical therapies. New antibiotic-resistant strains of
disease are a major threat to human health.
n Race is not a useful biological concept. Ethnicity
is a construct of cultural identity. Race is not a viable
biological concept, because it cannot be adequately
defined either genetically or phenotypically. Most
genetic variation can be found within so-called racial
groups, whereas the differences among groups are
extremely small and have little physiological signifi-
cance. All humans today are part of the same species.
The rule of racial hypodescent found in North America
and in some other countries—whereby the classifica-
tion of a child of mixed-race ancestry is determined
by assigning the child the “race” of his or her more
socially subordinate parent—illustrates that race is a
concept of folk biology rather than a useful scientific
category.
n Ethnicity is an important social construction,
and ethnic groups are sometimes thought to be
recognizably different by phenotype. Nearly all
the differences however, are in culture—dress, lan-
guage, religion, and so forth. Ethnicity is related to
subcultural differences in a pluralistic society, but
ethnic differences are commonly not just about cul-
ture but also about social class.
n Human biology is different from biomedicine
in its aims and scope. The study of human biology
is comparative. The explanation of human biological
variation is important to biologically oriented medi-
cal anthropologists; such variation requires careful
documentation and analysis using principles of adap-
tation and evolution. In biomedicine, such variation
is largely considered “noise” that sometimes compli-
cates the identification of a single etiology (cause) of
an illness and the prescription of a therapy. In human
biology, the history of particular populations is rele-
vant to understanding their characteristic genetic and
physiological traits. By doing cross-cultural compari-
sons, for example, anthropologists find that Western
girls reach puberty earlier than do girls in some other
places, and this physiological trend has both health
repercussions and reproductive implications. We
should not assume that a particular group (say, white
Americans) is the “normal” standard for growth pat-
terns, reactions to drugs, and so forth. Comparative
medical research is central to understanding human
biological variation.
 2
Stone Agers in the Fast Lane: Chronic Degenerative
Diseases in Evolutionary Perspective
S. Boyd Eaton
Marjorie Shostak
Melvin Konner
This classic selection was written for a medical journal by
anthropologist-physicians interested in using an evolution-
ary approach to explain what our diet and exercise patterns
should be if we want to prevent such chronic degenera-
tive diseases as cardiovascular disease, hypertension, and
some cancers. The primary argument here is that there
is a discordance, or biological estrangement, between our
genes and contemporary patterns of diet and activity. The
result of this discordance is that, in wealthy populations
across the world, a variety of chronic diseases have mark-
edly increased. These diseases, sometimes called diseases
of civilization, are largely preventable. The prescription is
a familiar one—a low-fat, high-fiber diet and an increase
in exercise—but the reasoning behind it is evolutionary.
The authors wrote a popular book on this subject (Eaton,
Shostak, and Konner 1988), and some cartoonists poked fun
at their work, calling it the “cave man diet.” But medical
anthropologists would argue that there are a lot of lessons
modern people could learn from so-called cave men.
Two of the authors (Shostak and Konner) did anthropo-
logical fieldwork among the !Kung San hunter-gatherers who
live in the Kalahari Desert in southern Africa. Hunter-
gatherers today cannot be thought of as some type of liv-
ing fossil; they are affected by significant historical and
political-economic pressures (Solway and Lee 1990). How-
ever, their lives more closely resemble those of our remote
ancestors—what this selection calls the “environment of
evolutionary adaptedness”—than ours do. Most anthropolo-
gists strongly believe that so-called modern people have a
lot to learn from so-called primitive people. Those practi-
cal lessons include not only diet and exercise but things
like breast-feeding patterns, child-rearing rules, and the
organization of schools.
Since the time this article was written, many scholars
have convincingly argued that our evolutionary herit-
age is more complex than what is presented here. For one
Understanding and Applying Medical Anthropology: Biosocial and Cultural Approaches (3rd ed.) by Peter J. Brown and Svea Closser, 27–38 © 2016
Taylor & Francis. All rights reserved. Chapter 2 original article source: S. B. Eaton, M. Shostak, and M. Konner. 1988. Stone Agers in the Fast
Lane: Chronic Degenerative Diseases in Evolutionary Context. American Journal of Medicine 84: 739–49.
thing, researchers have shown that, contrary to how they
are presented in this article, the diets of people in the Paleo-
lithic were very diverse. Some groups likely ate lots of lean
meat; others did not. Hunter-gatherer diets are of course
dependent on what’s available in the environment, so they
vary widely by ecosystem (Jabr 2013). As anthropologist
William Leonard has argued, humans evolved not for one
specific diet but to be “flexible eaters,” able to adapt to a
wide variety of ecological contexts (Leonard 2002).
Researchers have also pointed out that human genetic
evolution is ongoing, not stuck in the Paleolithic. One
example of this is the evolution of lactose tolerance. Our
hunter-gatherer ancestors didn’t consume dairy products.
But human populations that domesticated animals and
used fresh milk as a major food source mostly evolved a tol-
erance to lactose; populations that didn’t rely on milk did
not evolve that trait (leaving their descendants with what is
now referred to as “lactose intolerance”).
Some people have even argued that since human health
is always influenced by what went before, imagining a
Golden Age of perfect human adaptation is unrealistic. Just
as our bodies are shaped by our evolutionary history, the
bodies of our Paleolithic ancestors were shaped by their evo-
lutionary history (Zuk 2013).
Still, this classic article represents a useful way of
thinking—our evolutionary history does affect our health.
When you read this selection, think about your own health
or that of your friends and family. Do you smoke cigarettes
or drink alcohol? Do you eat a diet high in sugar and refined
carbohydrates? Do you get enough exercise? Why or why
not? How might our evolutionary heritage affect both our
behaviors and health?
As you read this selection, consider these questions:
n How can you tell that this selection was writ-
ten for physicians reading a medical journal?
27
28 Part I—Understanding Medical Anthropology: Biosocial and Cultural Approaches
What kind of assumption may be embedded in
this article regarding the nature and causation
of health?
n If there is a discordance in the evolution of
our genes and culture, why haven’t our genes
caught up?
n Can you devise an evolutionary explanation for
why we like to eat things (say, ice cream or alco-
hol) that are bad for us?
Context: This article was written in the early
days of the field of evolutionary medicine (a.k.a.
Darwinian medicine). Eaton’s primary inter-
ests were in the prevention of chronic disease,
whereas Konner and Shostak had done field
From a genetic standpoint, humans living today are
Stone Age hunter-gatherers displaced through time to
a world that differs from that for which our genetic
constitution was selected. Unlike evolutionary mala-
daption, our current discordance has little effect on
reproductive success; rather it acts as a potent pro-
moter of chronic illnesses: atherosclerosis, essential
hypertension, many cancers, diabetes mellitus, and
obesity among others. These diseases are the results of
interaction between genetically controlled biochemical
processes and a myriad of biocultural influences—
lifestyle factors—that include nutrition, exercise, and
exposure to noxious substances. Although our genes
have hardly changed, our culture has been trans-
formed almost beyond recognition during the past
10,000 years, especially since the Industrial Revolu-
tion. There is increasing evidence that the result-
ing mismatch fosters “diseases of civilization” that
together cause 75% of all deaths in Western nations
but that are rare among persons whose lifeways reflect
those of our preagricultural ancestors.
In today’s Western nations, life expectancy is over
70 years—double what it was in preindustrial times.
Infant death rates are lower than ever before and nearly
80% of all newborn infants will survive to age 65 or
beyond. Such vital statistics certify that the health of
current populations, at least in the affluent nations, is
superior to that of any prior group of humans. Accord-
ingly, it seems counterintuitive to suggest that, in cer-
tain important respects, the collective human genome
is poorly designed for modern life. Nevertheless, there
is both epidemiologic and pathophysiologic evidence
that suggests this may be so.
research on the !Kung San people of the Kalahari
Desert. After submitting an article in the prestig-
ious New England Journal of Medicine on this topic
in 1985, these three authors wrote a popular book
titled The Paleolithic Prescription: A Program of Diet
& Exercise and a Design for Living (1989). Boyd
Eaton is a physician, radiologist, and researcher
in the evolutionary medicine of chronic diseases
at Emory University. Melvin Konner is a biologi-
cal anthropologist and physician at Emory Uni-
versity; he is a prolific author, best known for his
volume The Tangled Wing: Biological Constraints on
the Human Spirit. The late Marjorie Shostak made
remarkable contributions to ethnographic writing
with her book Nisa: The Life and Words of a !Kung
Woman.
In industrialized nations, each person’s health sta-
tus is heavily influenced by the interaction between his
or her genetically controlled biochemistry and a collec-
tion of biobehavioral influences that can be considered
lifestyle factors. These include nutrition, exercise, and
exposure to harmful substances such as alcohol and
tobacco. This report presents evidence that the genetic
makeup of humanity has changed little during the
past 10,000 years, but that during the same period, our
culture has been transformed to the point that there
is now a mismatch between our ancient, genetically
controlled biology and certain important aspects of
our daily lives. This discordance is not genetic malad-
aptation in the terms of classic evolutionary science—it
does not affect differential fertility. Rather, it promotes
chronic degenerative diseases that have their main
clinical expression in the postreproductive period,
but that together account for nearly 75% of the deaths
occurring in affluent Western nations.
THE HUMAN GENOME
The gene pool from which current humans derive
their individual genotypes was formed during an
evolutionary experience lasting over a billion years.
The almost inconceivably protracted pace of genetic
evolution is indicated by paleontologic findings that
reveal that an average species of late Cenozoic mam-
mals persisted for more than a million years,1 by
biomolecular evidence indicating that humans and
chimpanzees now differ genetically by just 1.6% even
though the hominid-pongid divergence occurred
 2 Stone Agers in the Fast Lane: Chronic Degenerative Diseases in Evolutionary Perspective
seven million years ago,2 and by dentochronologic
data showing that current Europeans are genetically
more like their Cro-Magnon ancestors than they are
like 20th-century Africans or Asians.3 Accordingly, it
appears that the gene pool has changed little since
anatomically modern humans, Homo sapiens sapiens,
became widespread about 35,000 years ago and that,
from a genetic standpoint, current humans are still
late Paleolithic preagricultural hunter-gatherers.
THE IMPACT OF CULTURAL CHANGES
It has been proposed that chronic degenerative disor-
ders, sometimes referred to as the “diseases of civi-
lization,” are promoted by discordance between our
genetic makeup (which was selected over geologic
eras, ultimately to fit the life circumstances of Pale-
olithic humans) and selected features of our current
bioenvironmental milieu. The rapid cultural changes
that have occurred during the past 10,000 years have
far outpaced any possible genetic adaptation, espe-
cially since much of this cultural change has occurred
only subsequent to the Industrial Revolution of 200
years ago. The increasing industrialized affluence of
the past two centuries has affected human health both
beneficially and adversely. Improved housing, sanita-
tion, and medical care have ameliorated the impact
of infection and trauma, the chief causes of mortal-
ity from the Paleolithic era until 1900, with the result
that average life expectancy is now approximately
double what it was for preagricultural humans. The
importance of these positive influences can hardly be
overstated; their effects have not only increased lon-
gevity, but also enhanced the quality of our lives in
countless ways. But, on the other hand, the past cen-
tury has accelerated the biologic estrangement that
has increasingly differentiated humans from other
mammals over the entire two-million-year period
since Homo habilis first appeared. Despite the increas-
ing importance of culture and technology during this
time, the basic lifestyle elements of Homo sapiens sapi-
ens were still within the broad continuum of general
mammalian experience until recently. However, in
today’s Western nations, we have so little need for
exercise, consume foods so different from those avail-
able to other mammals, and expose ourselves to such
harmful agents as alcohol and tobacco that we have
crossed an epidemiologic boundary and entered a
watershed in which disorders such as obesity, diabe-
tes, hypertension, and certain cancers have become
common in contrast to their rarity among remaining
preagricultural and other traditional humans.
29
METHODS
Pertinent data on fitness, diet, and disease preva-
lence in nonindustrial societies were reviewed, tab-
ulated, and contrasted with comparable data from
industrialized nations. The literature cited is based
on studies of varied traditional groups: pastoralists,
rudimentary horticulturalists, and simple agricul-
turalists, as well as technologically primitive hunter-
gatherers. We would have preferred to present data
derived solely from studies of pure hunter-gatherers,
since they are most analogous to Paleolithic humans.
Unfortunately, only a few such investigations have
been performed, so that inclusion of selected non-
foraging populations constitutes a necessary first
approximation. However, there is a continuum of
human experience with regard to lifestyle factors
that now affect disease prevalence, and on this con-
tinuum, traditional peoples occupy positions much
closer to those of our preagricultural ancestors than
to those of affluent Westerners. In each case, the
groups analyzed resemble late Paleolithic humans
far more than us with respect to factors (such as exer-
cise requirements and dietary levels of fat, sodium,
and fiber) considered likely to influence the preva-
lence of the disease entity under consideration.
THE LATE PALEOLITHIC LIFESTYLES
The Late Paleolithic era, from 35,000 to 20,000 B.P.
[Before Present], may be considered the last time
period during which the collective human gene pool
interacted with bioenvironmental circumstances typi-
cal of those for which it had been originally selected.
It is because of this that the diet, exercise patterns, and
social adaptations of that time have continuing rel-
evance for us today.
Nutrition
The diets of Paleolithic humans must have varied
greatly with latitude and season just as do those of
recently studied hunter-gatherers; undoubtedly,
there were periods of relative plenty and others of
shortage; certainly there was no one universal sub-
sistence pattern. However, the dietary requirements
of all Stone Age men and women had to be met by
uncultivated vegetables and wild game exclusively;
from this starting point, a number of logically defen-
sible nutritional generalizations can be extrapolated.
(1) The amount of protein, especially animal protein,
30 Part I—Understanding Medical Anthropology: Biosocial and Cultural Approaches

TABLE 2.1 Late Paleolithic, Contemporary American, total daily sodium intake was less than a gram—
and Currently Recommended Dietary Composition barely a quarter of the current American average.
Late Contemporary
(10) Because they had no domesticated animals, they
Paleolithic American Current had no dairy foods; despite this, their calcium intake,
Diet Diet Recommendations in most cases, would have far exceeded that gener-
Total Dietary ally consumed in the 20th century.
Energy (percentage)
Protein 33 12 12
Carbohydrate
Fat
46
21
46
42
58
30
Physical Exercise
Alcohol ~0 7–10* –
P:S ratio 1.41 0.44 1.00 The hunter-gatherer way of life generates high levels
Cholesterol (mg) 520 300–500 300 of physical fitness. Paleontologic investigations and
Fiber (g) 100–150 19.7 30–60 anthropologic observations of recent foragers10 docu-
Sodium (mg) 690 2,300–6,900 1,100–3,300
Calcium (mg) 1,500–2,000 740 800–1,600
ment that among such people, strength and stamina
Ascorbic Acid (mg) 440 87.7 60 are characteristic of both sexes at all ages.
Skeletal remains can be used for estimation of
Updated from Eaton and Konner, note 4. Database now includes 43 species of
wild game and 153 types of wild plant food. strength and muscularity. The prominence of mus-
*Inclusion of calories from alcohol would require concomitant reduction in cular insertion sites, the area of articular surfaces,
calories from other nutrients—mainly carbohydrate and fat. and the cortical thickness and cross-sectional shape
P.S.: polyunsaturated-to-saturated fat. of long bone shafts all reflect the forces exerted by the
muscles acting on them. Analyses of these features
consistently show that preagricultural humans were
was very great. The mean, median, and modal pro- more robust than their descendants, including the
tein intake for 58 hunter-gatherer groups studied in average inhabitants of today’s Western nations. This
[the 20th] century was 34%,4 and protein intake in pattern holds whether the population being studied
the Late Paleolithic era may have been higher still.5,6 underwent the shift to agriculture 10,00011 or only
The current American diet derives 12% of its energy l,00012 years ago, so it clearly represents the results
from protein (Table 2.1). (2) Because game animals of habitual activity rather than genetic evolution.
are extremely lean, Paleolithic humans ate much less The fact that hunter-gatherers were demonstrably
fat than do 20th-century Americans and Europeans, stronger and more muscular than succeeding agri-
although more than is consumed in most Third- culturalists (who worked much longer hours) sug-
World countries. (3) Stone Age hunter-gatherers gen- gests that the intensity of intermittent peak demand
erally ate more polyunsaturated than saturated fat. on the musculoskeletal system is more important
(4) Their cholesterol intake would ordinarily have than the mere number of hours worked for the devel-
equaled or exceeded that now common in indus- opment of muscularity.
trialized nations. (5) The amount of carbohydrate The endurance activities associated with both
they obtained would have varied inversely with the hunting and gathering involve considerable heat pro-
proportion of meat in their diet, but (6) in almost all duction. The long-standing importance of such behav-
cases they would have obtained much more dietary iors for humankind is apparently reflected in the
fiber than do most Americans. (7) The availability of unusual mechanisms for heat dissipation with which
simple sugars, especially honey, would have varied evolution has endowed us: we are among the very
seasonally. For a two- to four-month period, their few animal species that can release heat by sweating;
intake could have equaled that of current humans, also, our hairless, exposed skin allows heat to escape
but for the remainder of the year it would have been readily, especially during rapid movement, like run-
minimal. (8) The amounts of ascorbic acid, folate, ning, when airflow over the skin is increased. These
vitamin B12, and iron available7,8 to our remote ances- physiologic adaptations suggest the importance of
tors equaled, and likely exceeded, those consumed endurance activities in our evolutionary past,13 and
by today’s Europeans and North Americans; prob- evaluation of recent preliterate populations confirms
ably this reflects a general abundance of micronutri- that their daily activities develop superior aerobic
ents (with the possible exception of iodine in inland fitness (Tables 2.2 and 2.3). Whereas actual meas-
locations). (9) In striking contrast to the pattern in urements of maximal oxygen uptake capacity have
today’s industrialized nations,9 Paleolithic humans been made almost exclusively on men, anthropologic
obtained far more potassium than sodium from their observations suggest commensurate aerobic fitness
food (as do all other mammals). On the average, their for women in traditional cultures as well.15
 2 Stone Agers in the Fast Lane: Chronic Degenerative Diseases in Evolutionary Perspective 31

TABLE 2.2 Aerobic Fitness

Maximal Oxygen Fitness

Subsistence Pattern Population Average Age Uptake (ml/kg/minute) Category*
Hunter-gatherers Canadian Igloolik Eskimos 29.3 56.4 Superior
Kalahari San (Bushmen) Young men 47.1 Excellent
Rudimentary horticulturists Venezuelan Warao Indians Young men 51.2 Excellent
New Guinea highland Lufas 25 67.0 Superior
Simple agriculturists Mexican Tarahumara Indians 29.8 63.0 Superior
Pastoralists Finnish Kautokeino Lapps 25–35 53.0 Superior
Tanzanian Masai 32–43 59.1 Superior
Industrialized Westerners Canadian Caucasians 20–29 40.8 Fair
Canadian Caucasians 30–39 38.1 Fair
Canadian Caucasians 40–49 34.9 Fair
*From note 14.

TABLE 2.3 Fitness Classification for American Males* Tobacco Abuse

Maximal Oxygen Uptake (ml/kg/minute)
Very
Age Poor Poor Fair Good Excellent Superior
20–29 <33.0 33.0–36.4 36.5–42.4 42.5–46.4 46.5–52.4
30–39 <31.5 31.5–35.4 36.5–40.9 41.0–44.9 45.0–49.4
40–49 <30.2 30.2–33.5 33.6–38.9 39.0–43.7 43.8–48.0
*Data modified from note 14.
Alcoholic Beverages
Honey and many wild fruits can undergo natural fer-
mentation, so the possibility that some preagricultural
persons had alcoholic beverages cannot be excluded.
However, widespread regular use of alcohol must
have been a very late phenomenon: of 95 preliterate
societies studied in this century,16 fully 46, including
the San (Bushmen), Eskimos, and Australian Aborigi-
nes, were unable to manufacture such beverages. It is
estimated that 7 to 10% of the average adult American’s
daily energy intake is provided by alcohol; such lev-
els are far in excess of what Late Paleolithic humans
could have conceivably obtained.
In general, native alcoholic beverages are pre-
pared periodically and drunk immediately.17 Their
availability is subject to seasonal fluctuation, and as
products of natural fermentation, their potency is far
less than that of distilled liquors. Their consumption
is almost invariably subject to strong societal conven-
tions that limit the frequency and place of consump-
tion, degree of permissible intoxication, and types of
behavior that will be tolerated. In small-scale prelit-
erate societies, drinking tends to be ritualized and
culturally integrated.18 Solitary, addictive, pathologic
drinking behavior does not occur to any significant
extent; such behavior appears to be a concomitant of
complex, modern, industrialized societies.17
Recent hunter-gatherers such as the San (Bushmen),
Aché, and Hadza had no tobacco prior to contact
with more technologically advanced cultures, but the
>52.5
>49.5 Australian Aborigines chew wild tobacco, so seasonal
>48.1 use by Paleolithic humans in geographically limited
areas cannot be excluded. However, widespread
tobacco usage began only after the appearance of
agriculture in the Americas, perhaps 5,000 years ago.
With European contact, the practice spread rapidly
throughout the world. Pipes and cigars were the only
methods employed for smoking until the mid-19th
century, when cigarettes first appeared. Cigarettes
had three crucial effects: they dramatically increased
per capita consumption among men; after World War
I, they made smoking socially acceptable for women;
and they made inhalation of smoke the rule rather
than the exception. Although the hazards of chewing
tobacco, snuff, pipes, and cigars are not insignificant,
the major impact of tobacco abuse is a postcigarette
phenomenon of this century.
HOW ALTERED LIFESTYLES FACTORS
AFFECT DISEASE PREVALENCE
In many, if not most, respects, the health of humans in
today’s affluent countries must surpass that of typical
Stone Agers. Infant mortality, the rate of endemic infec-
tious disease (especially parasitism), and the preva-
lence of posttraumatic disability were all far higher
25,000 years ago than they are at present. Still, patho-
physiologic and epidemiologic research conducted
over the past 25 years supports the concept that cer-
tain discrepancies between our current lifestyle and
that typical of preagricultural humans are important
risk factors for the chronic degenerative diseases that
32 Part I—Understanding Medical Anthropology: Biosocial and Cultural Approaches

account for most mortality in today’s Western nations.
These “diseases of civilization” are not new: Aretaeus
described diabetes 2,000 years ago, atherosclerosis has
been found in Egyptian mummies, paleolithic “Venus”
statuettes show that Cro-Magnons could be obese, and
the remains of 500-year-old Eskimo burials reveal that
cancer afflicted hunter-gatherers isolated from contact
with more technologically advanced cultures.19 How-
ever, the lifestyle common in 20th-century affluent
Western industrialized nations has greatly increased
the prevalence of these and other conditions. Before
1940, diabetes was rare in American Indians,20 but
now the Pimas have one of the world’s highest rates;21
hypertension was unknown in East Africans before
1930, but now it is common,22 and in 1912, primary
malignant neoplasms of the lungs were considered
“among the rarest forms of disease.”23 It is not only
because persons in industrialized countries live longer
that these illnesses have assumed new importance.
Young persons in the Western world commonly harbor
developing asymptomatic atherosclerosis,24 whereas
youths in technologically primitive cultures do not;25,26
the age-related rise in blood pressure so typical of afflu-
ent society is not seen in unacculturated groups,27 and
older members of preliterate cultures remain lean28–30 in
contrast to the increasing proportion of body fat that is
almost universal among affluent Westerners.31
Superimposed upon this underlying etiologic matrix,
however, are salient contrasts between the Late Paleo-
lithic era and the 20th century that increase the likeli-
hood of excessive weight gain (Table 2.4). (1) Most of
our food is calorically concentrated in comparison with
the wild game and uncultivated fruits and vegetables
that constituted the Paleolithic diet.4 In general, the
energy-satiety ratio of our food is unnaturally high:
in eating a given volume, enough to create a feeling
of fullness, Paleolithic humans were likely to con-
sume fewer calories than we do today.32 (2) Before
the Neolithic Revolution, thirsty humans drank
water; most beverages consumed today provide a
significant caloric load while they quench our thirst.
(3) The low levels of energy expenditure common in
today’s affluent nations may be more important than
excessive energy intake for development and main-
tenance of obesity.33 Total food energy intake actu-
ally has an inverse correlation with adiposity, but
obese persons have proportionately even lower lev-
els of energy expenditure—a low “energy through-
put” state. Increased levels33 of physical exercise
raise energy expenditure proportionately more than
caloric intake34 and may lower the body weight “set
point.”
Diabetes Mellitus

Obesity Mortality statistics for New York City between 1866

and 1923 show a distinct fall in the overall death rate,
Obesity is many disorders: its “causes”—genetic, but a steady, impressive rise in death rates from dia-
neurochemical, and psychologic—interact in a com- betes. For the over-45 age group, there was a 10-fold
plex fashion to influence body energy regulation. increase in the diabetic death rate during this period.35

TABLE 2.4 Triceps Skinfold Measurements in Males

Subsistence Pattern Population Age Thickness (mm)

Hunter-gatherers Australian Aborigines 25–29 4.7
Kalahari San (Bushmen) Young men 4.6
Canadian Igloolik Eskimos 20–29 4.4
Congo Pigmies 20–29 5.5
Tanzanian Hadza 25–34 4.9
Rudimentary horticulturists New Guinea Tukisenta 16–37 5.0
Venezuelan Warao Indians Young men 5.9
New Guinea Biak 25 5.3
Solomon Islanders 19–70 5.4
New Guinea Lufa 21–35 5.1
Surinam Trio Indians 21 and over 6.0
Simple agriculturists Peruvian Quechua Indians 35 4.0
Japanese Ainu Young men 5.3
Tarahumara Indians 21 and over 6.3
Rural Ethiopian peasants 20–30 5.3
Mean 5.2
Industrialized Westerners Canadian Caucasians 20–29 11.2
American Caucasians 18–24 9.0
Mean 10.1
 2 Stone Agers in the Fast Lane: Chronic Degenerative Diseases in Evolutionary Perspective
TABLE 2.5 Diabetes Prevalence
Subsistence Prevalence
Pattern Population (percentage)
Hunter- Alaskan Athabaskan Indians
gatherers Greenland Eskimos
Alaskan Eskimos
Rudimentary Papua, New Guinea Melanesians
horticulturists Loyalty Island Melanesians
Rural Malaysians
Simple Rural villagers, India
agriculturists “New” Yemenite immigrants,
Israel
Rural Melanesians, New
Caledonia
Polynesians on Pukapuka
Rural Figians
Pastoralists Nomadic Broayas, North Africa
Mean
Industrialized Australia, Canada, Japan, United 3.0–10.0*
Westerners States Range
*Data are from note 41.
This pattern anticipated the more recent experience of
Yemenite Jews moving to Israel,36 Alaskan Eskimos;37
Australian Aborigines,38 American Indians,39 and
Pacific Islanders of Micronesian, Melanesian, and
Polynesian stock.40 In these groups, diabetic preva-
lence, if not the actual mortality rate, has risen rapidly
and it has been observed that obesity and maturity-
onset diabetes are among the first disorders to appear
when unacculturated persons undergo economic
development. At present, the overall prevalence of
non-insulin-dependent diabetes among adults in
industrialized countries ranges from 3 to 10%,41 but
among recently studied, unacculturated native popu-
lations that have managed to continue a traditional
lifestyle, rates for this disorder range from nil to 2.0%
(Table 2.5).
Like obesity, diabetes mellitus is a family of
related disorders, each of which reflects the inter-
play of genetic and environmental influences. But
again, in comparison with Paleolithic experience, the
lifestyle of affluent, industrialized countries potenti-
ates underlying causal factors to promote maturity-
onset diabetes by several mechanisms. (1) A 1980
World Health Organization expert committee on
diabetes concluded that the most powerful risk fac-
tor for type II diabetes is obesity.42 The obese persons
common in Western nations have reduced numbers
of cellular insulin receptors. They manifest a rela-
tive tissue resistance to insulin,43 and therefore their
blood insulin levels tend to be higher than those of
lean persons. (2) Conversely, high-level physical fit-
ness, characteristic of aboriginal persons, is associ-
ated with an increased number of insulin receptors
and better insulin binding;44 these effects enhance the
33
body’s sensitivity to insulin.45 Serum insulin levels
are typically low in hunter-gatherers46 and trained
athletes;44 cellular insulin sensitivity can be improved
by physical conditioning that increases cardiorespi-
1.3
1.2 ratory fitness.47 This effect is independent from,47 but
1.9 may be augmented by, an associated effect on body
0.9 weight and composition.43 (3) Diets containing ample
2.0 amounts of nonnutrient fiber and complex carbohy-
1.8
1.2
drate have been shown to lower both fasting and
0.1 postprandial blood glucose levels.48 Diets with high
intakes of fiber and complex carbohydrates are the
1.5 rule among technologically primitive societies, but
are the exception in Western nations. The recommen-
1.0
0.6 dation by the American Diabetes Association under-
0.0 scores the merit of these Paleolithic dietary practices.
1.1
Hypertension
Across the globe, there are many cultures whose
members do not have essential hypertension nor
experience the age-related rise in average blood
pressure that characterizes populations living in
industrialized Western nations. These persons are not
genetically immune from hypertension since, when
they adopt a Western style of life, either by migration
or acculturation, they develop, first, a tendency for
their blood pressure to rise with age and, second,
an increasing incidence of clinical hypertension.27,49
These normotensive cultures exist in varied climatic
circumstances—in the arctic, the rain forest, the
desert, and the savanna—but they share a number
of essential similarities, each of which is the recip-
rocal of a postulated causal factor for hypertension.
These include diets low in sodium and high in potas-
sium.50 In addition, the pastoralists and those groups
still subsisting as hunter-gatherers have diets that
provide a high level of calcium.51 These persons are
slender,52 aerobically fit,53 and, at least in their unac-
culturated state, have limited or no access to alco-
holic beverages.54
More than 90% of the hypertension that occurs
in the United States and similar nations is idiopathic
or “essential” in nature. Many theories about the ori-
gin of this hypertension have been advanced and it
may represent a family of conditions that share a final
common pathway resulting in blood pressure eleva-
tion. Although its “causes” remain obscure, its occur-
rence in most cases probably reflects the interaction
between individual genetic predisposition and perti-
nent modifiable lifestyle characteristics. Accordingly,
a promising approach to its prevention is suggested
by the practices of traditional persons who are spared
this disorder; the common features they share reflect
components of our ancestral lifestyle.
34 Part I—Understanding Medical Anthropology: Biosocial and Cultural Approaches

Atherosclerosis TABLE 2.6 Serum Cholesterol Values

Subsistence Cholesterol
Clinical and postmortem investigations of arctic Pattern Population Gender Value (mg/dl)
Eskimos,55–57 Kenyan Kikuyu,58 Solomon Islanders,59 Hunter- Tanzanian Hadza M 114
Navajo Indians,60 Masai pastoralists,61 Australian gatherers F 105
Aborigines,62 Kalahari San (Bushmen),30 New Guinea Kalahari San M 130
highland natives,63 Congo Pygmies,64 and persons (Bushmen)
F 109
from other preliterate societies reveal that, in the
Congo Pygmies M 101
recent past, they experienced little or no coronary F 111
heart disease. This is presumably because risk factors Australian M 146
for development of atherosclerosis were so uncom- Aborigines
mon in such cultures. Like our Paleolithic ancestors, F 132
Canadian Eskimos 141
they traditionally lacked tobacco, rarely had hyper- Rudimentary Palau Micronesians M 160
tension, and led lives characterized by considerable horticulturists F 170
physical exertion. In addition, their serum cholesterol New Guinea 130
levels were low (Table 2.6). The experience of hunter- Chimbu
gatherers is of special interest in this regard: their diets New Guinea Wabag 144
Brazilian Xavante M 107
are low in total fat and have more polyunsaturated Indians
than saturated fatty acids (a high polyunsaturated- F 121
to-saturated fat ratio), but contain an amount of cho- Brazalian Kren- 100
lesterol similar to that in the current American diet. Akorore Indians
Solomon Islands M 135
The low serum cholesterol levels found among them
Aita
suggest that a low total fat intake together with a high F 142
polyunsaturated-to-saturated fat ratio can compen- Solomon Islands M 114
sate for relatively high total cholesterol intake.65 This Kwaio
supposition is supported by the experience of South F 125
New Guinea Bomai M 130
African egg farm workers. Their diets include a mean F 140
habitual cholesterol intake of 1,240 mg per day, but New Guinea M 139
fat (polyunsaturated-to-saturated fat ratio = 0.78) pro- Yongamuggi
vides only 20% of total energy, and their serum cho- F 140
lesterol levels average 181.4 mg/dl (with high-density Simple Mexican M 136
agriculturists Tarahumara Indians
lipoprotein cholesterol = 61.8 mg/dl).66 F 139
The adverse changes that occur in atheroscle- Rural Samoans M 167
rotic risk factors when persons from societies with F 180
little such disease become Westernized recapitulate Guatemalan Mayan M 132
Indians
the pattern observed for the other diseases of civi-
F 143
lization. The experiences of Japanese,67 Chinese,68 Pastoralists Kenyan Samburu M 166
and Samoans69 migrating to the United States, of Kenyan Masai F 135
Yemenite Jews to Israel,70 and of Greenland Eskimos
to Denmark71 parallel those of Kalahari Bushmen,72
Solomon Islanders,59 Ethiopian peasants,73 Canadian
Eskimos,74 Australian Aborigines,38 and Masai Pasto- class fatty acids.86 The latter, in turn, are related to die-
ralists75 who have become increasingly Westernized tary intake of fats containing these constituents; fish
in their own countries. oils have especially high concentrations of such fatty
Abnormalities of coagulability may contribute to adds. Meat from domesticated animals is deficient
both the development and the acute clinical manifesta- in this regard,87 but the wild game consumed by our
tions of atherosclerosis.76 Platelet function has received ancestors contained a moderate amount,4,87 possibly
considerable attention in this respect.77 Fibrino- enough to induce blood levels comparable to those of
lytic activity is enhanced by physical exercise,78 but the Japanese88 or Dutch,89 although almost certainly
decreased by smoking cigarettes,79 obesity,80 and hyper- not those of the Eskimos.71
lipoproteinemia,81 so it is not surprising that preliter- Coronary atherosclerosis was apparently uncom-
ate peoples have more such activity than do average mon in the United States before about 1930,90,91 but
Westerners.82,83 Platelet aggregation is influenced by its importance thereafter rapidly increased to a peak
hypercholesterolemia,84 by physical exercise,85 and by in the 1960s, then began a gradual decline. Whereas
blood levels of long-chain polyunsaturated omega-3 many factors ranging from changes in the diagnostic
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN