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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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