A. Returning to Social Medicine: A South African Experiment
One such experiment in constructing a national health service began in South Africa in the late 1930s, culminating in the founding of the Pholela (also spelled Polela) Health Center in 1940 and the Institute of Family and Community Health (IFCH) in 1945. Pholela was a small rural clinic where an interdisciplinary team of clinicians, epidemiologists, and health workers first worked out the ideas of community health care used over the next five decades. Pholela is to international primary care what the city of Framingham, Massachusetts, is to the epidemiology of heart disease: a place where pioneering methods led to critical new knowledge.
The Pholela project merits extended attention here because it was the first health-care service specifically designed to assess the health status of a community using social science and epidemiologic methods. It drew on those assessments to develop and evaluate a comprehensive multi-disciplinary approach to improving community health. Many of the assumptions guiding research at Pholela were similar to those explored by nineteenth-century proponents of social medicine: poverty and social class are important determinants of health; social and cultural change affect the transmission of illness; and group as well as individual interventions promote health and prevent disease. The editors of the major book about the project acknowledged these similarities, titling their book A Practice of Social Medicine (Kark and Steuart 1962).
Reflecting on the Pholela project a decade after its inception, the first medical director, Sidney Kark, commented on the gains made after the first year of the experiment:
The whole process of the health centre's development was one which reflected an increasing understanding of the individual in terms of his family situation, of the family in its life situation within the local community and finally the way of life of the community itself in relation to the social structure of South Africa. By this detailed study the centre had moved from the plane of vague generalization about the importance of various social forces to an increasing understanding of those forces in relation to health and disease as manifested in individuals. (1951:677)
The significance of Pholela was that connections between social relationships and health were made an essential part of daily health center practice (Ibid.). The staff of the health center used epidemiology, especially a socially oriented epidemiology, to develop and evaluate the practice of community-oriented primary health care (COPC). They focused on social and cultural factors in the growth and development of children, the social causes of sexually transmitted diseases, nutrition and health, and evaluation of COPC's effect on health status. It is remarkable that South Africa, home to one of the world's most repressive political regimes in the latter part of the twentieth century, was earlier the site of the most creative experiment in combining insights of social science and epidemiology to describe and improve human health.
The biographies of Sidney Kark and of Emily Kark, his wife, help to explain the origins of the anthropological aspects of their research. As medical students they were influenced strongly by their association with the South African Institute of Race Relations (S. and E. Kark: personal communication), and in 1934 they began the "Society for the Study of Medical Conditions among the Bantu." In 1939 Sidney Kark was selected by the Ministry of Health to head a new health center in Pholela, a small rural African community in the province of Natal.
The Pholela Health Center was a pilot project designed to deliver effective and appropriate health services to rural South African communities. From its inception the Center was concerned with the social and cultural life of the surrounding community. The first activities of the Center included meeting with tribal chiefs and elders to discuss the program. The staff also consulted women's groups, local missionaries, school teachers, and parents of schoolchildren. The community health educators made multipurpose home visits to educate the community, learn about local health beliefs and practices, and identify those people most responsible for the dissemination of news and new ideas. Health center staff created an innovative gardening program, wherein people were given seeds, taught how to grow new vegetable varieties, and shown how to prepare a variety of nutritious dishes that conformed with local preferences; in addition they created a cooperative seed-buying project and community market. Early clinical work included examining schoolchildren, initiating a general medical clinic, and establishing a maternal and child health program. An epidemiological survey was conducted door-to-door to ascertain the health status of the community. The combination of survey work and action programs led the team to develop the concept of community health diagnosis, which includes monitoring a community's health as well as identifying targets for intervention (Kark and Kark 1981).
The Pholela Health Center was very successful: in 1944 the South African National Health Services Commission recommended that more than 40 new health centers throughout South Africa be constructed and administered according to the Pholela model. The IFCH was created under S. Kark's direction to train staff for the new health centers, conduct research, and practice family and community medicine. The Institute included seven health centers; the one at Pholela was its rural community health center, and six new centers were established by the Institute in and around the city of Durban to serve communities of various incomes and ethnicities. Each of these centers provided primary health care and served as a source of information for cross-cultural comparative research on topics such as child rearing, infant mortality, and menarche.
The Karks continued their training in epidemiology and social science: in 1947-1948 they studied epidemiology at John Ryle's new Institute of Social Medicine at Oxford University, and they worked with E. E. Evans-Pritchard, Meyer Fortes, and Max Gluckman, the primary forgers of British social anthropology at that time. The Karks analyzed much of their Pholela data in Gluckman's methodology seminar and in discussions with Fortes and Evans-Pritchard. In that setting they were able to refine their ideas about a socially oriented epidemiology (S. and E. Kark: personal communication).
Though it began optimistically, by the late 1940s the attempt to develop a South African National Health Service was under siege, and conservative politics eventually led to its failure. The infamous apartheid policy began to be assembled in 1948 with the election of a conservative government. Activists and dissenters interested in social equity and social medicine were harassed by the government over the next few decades, and many decided to emigrate.
B. The Human Resources and Intellectual Legacy of the IFCH
When the South African government closed the IFCH in 1960, it signaled an end to its experiment in social medicine. Nevertheless the ensuing diaspora ensured that the IFCH staff, ideas, and methods would spread around the globe. A list of IFCH members who emigrated in the 1950s and early 1960s reads almost like a Who's Who of late-twentieth-century research and action in social medicine and social epidemiology (see Davey Smith and Susser 2002, Trostle 1986b).
The Karks emigrated to Israel in 1959, and they were joined there by other IFCH staff who had been invited to serve in the expanded program at Hebrew University. They began work in what soon evolved into the Department of Social Medicine (later the School of Public Health and Community Medicine) at the Hebrew University-Hadassah Medical School in Jerusalem. The group's ideas on how to incorporate epidemiology and social science into the delivery of health services to communities were presented in texts such as Epidemiology and Community Medicine (Kark 1974) and The Practice of Community-Oriented Primary Health Care (Kark 1981). Their ideas about how to make epidemiology a functional tool of health center practice were included in Survey Methods in Community Medicine (Abramson and Abramson 1999) and Making Sense of Data (Abramson and Abramson 2001).
Other South Africans associated with the IFCH went to Uganda and Kenya, where they founded health programs emphasizing preventive medicine much as was practiced at the IFCH. Still others came to the United States to apply their IFCH experiences to work in community health centers and major universities. For example, Mervyn Susser and Zena Stein, health center physicians deeply influenced by their work in the IFCH in the late 1950s (Oppenheimer and Rosner 2002, Susser 1993), came to the United States via Britain and became central figures in the development of epidemiology and public health in the United States (Davey Smith and Susser 2002). Susser was editor of the American
Journal of Public Health, co-authored an important text in medical sociology, and wrote many fundamental books and articles on epidemiologic theory (e.g., Susser 1973, 1987; Susser and Susser 1996). Stein was a leader in analyzing the relationship between maternal age and birth defects, as well as an important early proponent of developing methods women could use to prevent HIV infection (Stein 1985, 1990). The work ofthe IFCH also attracted foreign nationals, two ofwhom were important to the growth of social medicine and social epidemiology in the United States. Anthropologist Norman Scotch spent 18 months at the IFCH doing research on the causes ofhypertension among the Zulu (e.g., Scotch 1960, 1963b), and soon afterward he wrote one of the first reviews of literature in the field of medical anthropology (Scotch 1963a). Scotch, who eventually came to direct the School of Public Health at Boston University, devoted a significant part of this review to epidemiology. He asserted that epidemiology at that point was essentially a method that looked at the combined influence of biology, environment, society, and culture on human health. He reviewed the application of epidemiology to diseases like kuru in New Guinea, psychopathology among the Eskimo, and hypertension among the Zulu, pointing out the broad attention paid to social change as a causal factor in all these cases.
H. Jack Geiger did a clerkship at the IFCH when he was a medical student at Case Western University and later published with Scotch on social factors influencing arthritis and hypertension (Scotch and Geiger 1962, 1963). In the United States Geiger became influential in the social medicine and community health center movements (e.g., Geiger 1971) and was a co-founder of major antinuclear and human rights groups (Physicians for Social Responsibility and, later, Physicians for Human Rights). Geiger clearly acknowledged his indebtedness to S. Kark and his colleagues (1984:17). COPC was promoted as a workable goal for medicine in the United States, and more than 600 federally funded community health centers existed in the United States at the peak of this movement in the 1970s (Geiger 1993, Mullan 1982). Two other U.S. experiments in providing health care duplicated many aspects of the IFCH: the Navajo-Many Farms Project in the late 1950s (see Adair and Deuschle 1970) and the Tufts-Delta Health Center from 1965 to the present (see Geiger 1971). Like the IFCH, each of these also was designed to deliver health care to urban and rural populations, and each also developed innovative methods that combined the social sciences with medicine and epidemiology. COPC also was successful in many other countries (Susser 1999, Tollman 1994).
The ideas and methods initiated at Pholela and the IFCH thus were disseminated throughout the world, helping to spawn similar projects in other areas. Phoelela and the IFCH showed that a combination of epidemiologic and social science methods could better understand the extent of community health problems, direct the focus of curative and preventive measures, and evaluate the effectiveness of these measures. Perhaps most important from an anthropological point of view, the IFCH experience taught its staff the importance of gaining cultural understanding (Kark and Kark 1962). This emphasis can be seen clearly in many of the projects and publications that resulted after the project halted and its staff scattered, in particular, in the work of John Cassel.
C. From Practice to Process: Unpacking the Social and Cultural Environment
For our purposes one of the major ideas to emerge from staff trained at the IFCH was a conceptual framework for analyzing the social and cultural processes relevant to health. This framework was developed by an interdisciplinary team at the University of North Carolina, Chapel Hill, led by John Cassel, a former IFCHphysician/epidemiologist, and the team also included an anthropologist (Donald Patrick) and a psychologist (David Jenkins).
Cassel was a South African physician who had joined the Pholela Health Center in 1948. The importance of the Pholela experience to Cassel's later work cannot be overestimated. His close contact with the health problems of the Pholela community, and the fact that his own attempts at curative and preventive care sometimes met competition from traditional medical beliefs and practices, helped him to develop an interest in the social and cultural components of health. This interest is stated most clearly in anthropological terms in a chapter titled "Cultural Factors in the Interpretation of Illness: A Case Study" (Cassell 1962). This case study is presented "as an illustration of the insight provided by knowledge of the cultural patterning and social situation into behavior which would otherwise appear as a series of inexplicable unrelated acts" (1962:238). It describes how two related kin groups in Pholela managed cases of pulmonary tuberculosis, cervical cancer, and persistent headaches, and it shows how knowledge of a series of related witchcraft accusations helped explain the management strategies chosen by kin groups and a missionary who became involved in the case.
Cassel also described the importance of cultural understanding in the Pholela project in his lead chapter in Benjamin Paul's classic 1955 text, Health, Culture, and Community. There he analyzed the different levels of Zulu resistance to the Pholela staff's curative and preventive efforts. Attempts by the staff to change attitudes toward food; to increase production and consumption of vegetables, eggs, and milk; to treat pulmonary tuberculosis; or to combat soil erosion - each was met by a higher level of resistance. The male labor out-migration created by South African labor regulations brought syphilis and tuberculosis into the community and challenged long-term treatment regimes for working-age males. Local unemployment and population pressure, combined with traditional food preferences and land use patterns better adapted to another time and place, helped make soil erosion a serious problem and malnutrition a common diagnosis (Cassel 1955:35). Understanding which cultural patterns were easiest to modify allowed the workers at Pholela to target their efforts toward reasonable goals; knowing who held power in the community allowed them to focus their actions on potential change-agents. Measurable health improvements were seen throughout the course of the project, especially in infant mortality, incidence of infectious diseases, and prevalence of malnutrition.
Cassel left South Africa in 1954 to join the School of Public Health at the University of North Carolina (UNC) at Chapel Hill. There he developed a strong joint faculty in the social sciences and epidemiology. Researchers in North Carolina confronted a largely agricultural state in the process of developing a postwar industrial base. The impact of society and culture on health was not as dramatic or life-threatening there as it had been in Pholela. Nonetheless, the studies undertaken by Cassel and colleagues in North Carolina eventually showed the equally significant health effects of such diffuse social processes as social and cultural change and adaptation. Cassel's conceptualization (1976) ofthe effects of the social environment on host resistance is his classic work; one measure of its importance is that it has been cited more than 800 times since publication.
The interdisciplinary team Cassel led at UNC-Chapel Hill published one of the first papers in social epidemiology to separate explicitly the social system from the cultural system. Acknowledging the work of the anthropologist Clifford Geertz, the authors defined culture as "the fabric of meaning in terms of which people interpret their experience and guide their action," while they defined social structure (which they equated with society) as "the way that group life is ordered, the persistent and regular social relationships of people" (Cassel et al. 1960:945). These distinctions were used to differentiate between the appropriateness ofcul-tural norms and three different forms of social organization within which norms applied: occupation, family, and social class. Specific hypotheses could be tested within each of these three arenas. This paper showed the growing theoretical sophistication of researchers in social epidemiology. With the increasing general acceptance of the etiological importance of the social and cultural environment, it became necessary to develop theoretical models that could account for the obvious complexity of this environment.
In 1960, Cassel's team proposed an epidemiological study of the changes in health status that might accompany changes from a rural agricultural to an industrial way of life. Designed to take place in a manufacturing plant in a small Appalachian town, the study would compare three groups of people: agricultural workers, first-generation factory employees, and second- and third-generation factory employees. The authors hypothesized that the first-generation workers, those experiencing the greatest cultural change, would have poorer health status than the other groups. They also hypothesized that less family solidarity and greater incongruity between cultural background and current social situation would be most closely associated with poor health and adjustment. The research confirmed many of their hypotheses (Cassel and Tyroler 1961). Using measures of general morbidity and of absenteeism due to illness, the results showed that the health status of the first factory workers to move into the industrial area was lower than the health status of factory workers whose relatives already had been employed in the factory.
Under Cassel's influence, two other research topics linked epidemiologists and anthropologists at UNC-Chapel Hill: the epidemiologic study of diseases not recognized by biomedicine and the protective effects of social support on health. The medical anthropologist Arthur Rubel used his training in epidemiology at UNC-Chapel Hill to develop studies of the Mexican folk illness susto (Rubel 1964). This was one of the first times that the methods of epidemiology were applied to disease entities defined according to non-Western categories in an effort to understand their distribution and cause, even if they did not fit biomedical assumptions.
The second theme was a series of studies that established the protective health effects of social support, such as marital ties, friendships, and membership in community organizations. This work from the early 1970s helped to demonstrate the importance of host susceptibility and resistance - that is, factors that either increase or decrease the likelihood that an individual will become ill. Social support subsequently became a popular focus for studies in social epidemiology (Berkman and Kawachi 2000, Berkman and Syme 1979), but the anthropological origin of epi-demiological interest in social support has largely been forgotten.
The UNC-Chapel Hill research has had a profound impact on social epidemiology. If the South African contribution is typified broadly as understanding how to provide and measure the benefits of health care to communities, the UNC-Chapel Hill work might be typified as developing epidemiological strategies to measure the health effects of social and cultural change. The new social medicine practiced in South Africa had its roots firmly (and knowingly) planted in a nineteenth-century sociological epidemiology; the UNC-Chapel Hill research on the effects of social and cultural change had an unacknowledged affinity with this same nineteenth-century work. For example, Rudolf Virchow wrote that epidemic diseases were markers of cultural change. While considering the contemporary epidemics of the industrial world - cancer, heart disease, stroke, other chronic diseases, accidents - Virchow's words maintain their significance: "The history of artificial epidemics is therefore the history of disturbances which the culture of mankind has experienced. Its changes show us with powerful strokes the turning points at which culture moves off in new directions" (Virchow, Report on the Typhus Epidemic in Upper Silesia, quoted in Rosen 1947:681).
D. Redefining the Social Environment through Medical Ecology
I have paid specific attention to the research developed by Cassel and colleagues because of its relevance to contemporary social epidemiology and because of its links to the IFCH and South Africa. But by highlighting the research produced by specific people, I risk ignoring the broader intellectual surroundings that nourish such work. One critical part of this context consists of the ongoing attempts made in the twentieth century to define and understand the etiologic influence of the social environment.
The collaborative work between anthropologists and epidemiologists that began in the late 1950s came at a time of redefinition in epidemiology: articles at the time stated the field of epidemiology was "returning in large measure to the physicochemical and sociological orientation of the first half of the 19th century, but on a much sounder scientific basis than was possible at that time" (Terris 1962:1375). A number of epidemiology textbooks in the late 1950s defined epidemiology as applying to any and all diseases, infectious or chronic, and also stated the importance of the social environment as a factor in disease. Early literature reviews in the developing field of medical anthropology also started to discuss epidemiology at about this time (see Caudill 1953, Polgar 1962, and Scotch 1963a). Explicitly and consciously, the two fields were converging.
In 1958 the first paper was published stating explicitly that the disciplines of anthropology and epidemiology had noteworthy parallels (Fleck and Ianni 1958). Perhaps because it appeared in a journal of applied anthropology, the paper provoked little comment by epidemiologists (Fleck: personal communication; Ianni: personal communication). It emphasized the social aspects of the research by Panum, Snow, and other nineteenth-century epidemiologists and also discussed the difficulties of modern-day collaboration between anthropologists and epidemiologists. One primary difficulty was that anthropologists working in applied so-ciomedical research were commonly included only as consultants: they had little control over the nature of the questions being asked and learned little about epidemiology. Another problem was that epidemiologists historically had been too concerned with disease agents: these authors had high hopes for what they called an emerging "neoecological approach" in epidemiology, which would place greater emphasis on multiple causality and the importance of the environment. They also emphasized the importance of disease classification to epidemiology by remarking that "[t]he epidemiologist must be and is a social anthropologist with his particular interest being nosology" (1958:39).
Fleck and Ianni were correct in their estimates of the power of the emerging ecological approach in epidemiology, although their hopes for significant increases in anthropological engagement in this work would not be realized for two decades. Medical ecology was defined in the 1950s as an analytical perspective that focused on "the study of the populations of man with special reference to environment and to populations of all other organisms as they affect his health and his numbers" (Audy 1958:102). This interest had grown rapidly during World War II, when geographers mapped disease distributions and ecological habitats as part of the battles fought against tropical diseases in South East Asia. A well-known medical geographer once proposed that the term "medical geography" be replaced with the words "human ecology of health and disease" (May 1978 :212). But medical geography emphasizes the spatial aspects of disease distribution, whereas medical ecology stresses the organizational aspects of disease distribution. In contrast to a medical geographer's questions about place and time, a medical ecologist might investigate the manifestations of a disease at different ecological levels -cellular, individual, community, or population - and would consider the interactions among these levels.
One important result of the exchanges among medical ecology, medical geography, and epidemiology in the 1950s was that researchers were given further theoretical justifications for including the social environment in the study of the distribution and determinants of diseases. One researcher wrote that "the notable addition to the content of epidemiology under the influence of ecology is in relation to the social environment" (Gordon 1958:351).A1960 text titled Human Ecology and Health expressed similar ideas:
Public health has always been concerned with man and his environment and, in this sense, oriented toward human ecology - though in a somewhat limited fashion at first. Today, however, the significance and the meaning of the term environment have acquired new proportions. Environment in this sense includes, of course, not only the material and spatial aspects of man's world but the nonmaterial web of human social relations called culture which profoundly influences man's state. (Rogers 1960:vii, emphasis in the original)
This emerging interest in ecology and health had two outcomes relevant to our theme. First, anthropologists began to be used to gain entree into the field. In 1965, for example, members from the disciplines of epidemiology, social anthropology, entomology, sanitary engineering, public health nursing, and laboratory science embarked on an ambitious international comparative research project at the Geographical Epidemiology Unit at The Johns Hopkins University, designed to study the ecology of disease in five developing countries. The project team eventually published studies from Peru, Chad, and Afghanistan (Bucket al. 1968, 1970, 1972). The role of the social anthropologist in these studies was to collect contextual socioeconomic and cultural data and to facilitate the acceptance of the project within each study area. A cross-culturally applicable interview schedule was designed and translated into the respective national languages. Key informants were interviewed to obtain information about the different villages and cultures. But despite mention of the type and schedule of agricultural work, recency of settlement, frequency of out-migration and in-migration, and rapidity of social change, few systematic attempts are made in these three works to link the social and cultural environment with the descriptive epidemiology of tropical diseases. The social and cultural information serves as context, but the research was undertaken more to describe this context than to analyze its relationship to human health and disease.
Although psychological studies are not a primary focus of this chapter, it is important to mention that the mental health effects of social and cultural disorganization were being studied in the 1950s and 1960s alongside studies of the physical health effects of culture change. Perhaps the most important group engaged in the study of social disorganization and mental health at that time was formed by psychiatrists, anthropologists, and epidemiologists associated primarily with Cornell University. The group included a large number of senior anthropologists, including MarcAdelard Tremblay, Charles Hughes, Norman Chance, Jane Hughes, and Robert Rapoport. The project directors (Alexander and Dorothea Leighton) were psychiatrists who held joint appointments in the Department of Anthropology. The first stages of the project involved more than
12 years of community fieldwork in an area of Nova Scotia they called Stirling County. They determined the prevalence of psychiatric dysfunction by having clinicians interview residents, and they compared this prevalence across the communities when arrayed along a spectrum of social disintegration. In all, 33 people participated in anthropological work over the first 10 years of the project (Hughes et al. 1960:531), and the project continues to this day (see Murphy 1994b, Murphy et al. 2000).
The authors described anthropological data collection as part of "a total approach to the County and its communities" (Hughes et al. 1960:7). Anthropological data would help readers understand epidemiological findings, as they put it, "so that as rich a background as possible is provided for understanding the context of the varying tendencies with regard to both prevalence and type of symptom pattern" (Ibid.:8). In a tradition that we have seen extending back to Peter Panum almost 100 years before, the authors were involved as participant observers:
[M]embers of our team have variously lived as neighbors, have grown gardens, cut timber from their own woodlots, fished on the bays, hauled lobsters, held offices in societies, taught nursery school, participated in the weddings, christenings, and funerals of friends and in turn had these friends share with us our own joys in new marriage and the birth of babies, and our sadnesses and fear when confronting sickness and death. (Ibid.:7)
Given our reference to Rudolf Virchow as a key nineteenth-century figure in the history of anthropology and epidemiology, it is important to note that one volume of the Stirling County report (The Character of Danger: Psychiatric Symptoms in Selected Communities, 1963) is dedicated to Virchow's memory, and its title is extracted from his writing on how to differentiate pathological from normal physiological processes. Virchow wrote that pathological processes are hard to distinguish from ordinary life processes, even consisting, at times, of ordinary processes happening at the wrong time or place. The Leightons and their colleagues thought that psychiatric disturbances were similarly difficult to define through sites of brain lesions or psychodynamic theories about how the mind functioned, so they used Virchow's approach to malfunction to justify assessing psychiatric status based on the type, frequency, and duration of impairment posed by psychiatric symptoms (Leighton and Murphy 1997).
This project, and similar population-based studies of mental functioning, created an early precedent for the contemporary interest ofepidemi-ologists in human communities and their effects on health. As noted earlier, they realized the importance of establishing close and enduring relationships with communities under study, much as any anthropological participant observer would. They also clearly described the need for collaborative work between anthropologists and epidemiologists.
The Leightons' studies of mental illness and the UNC-Chapel Hill studies of physical illness started in the 1950s, when anthropologists were becoming interested in the concepts of acculturation (Beals 1953) and culture change (Lange 1965). However, while theories about the nature and effects of social and cultural change became increasingly useful in social epidemiology (Cassel 1964) and psychiatric epidemiology (Leighton et al. 1963), the applied epidemiological studies that explored the health consequences of such change had little impact on further theorizing in anthropology until the 1990s (see Chapter 3).
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