The Intersectionality of Sociology and Health: Case Studies of the Effect of Culture on Disease

The intersectionality of sociology and health: case studies of the effect of culture on disease

Margaret Loy Khaitsa^1,&, John Baligwamunsi Kaneene², Naomi Watasa Lumutenga³, May Sengendo⁴

¹Department of Pathobiology and Population Medicine, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi, USA, ²Center for Comparative Epidemiology, Michigan State University, East Lansing, Michigan, USA, ³Higher Education Resource Services, East Africa, 401 Senate Building, Makerere University, Kampala, Uganda, ⁴School of Women and Gender Studies, Makerere University, P.O. Box 7062 Kampala, Uganda

^&Corresponding author
Margaret Loy Khaitsa, Department of Pathobiology and Population Medicine, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi, USA

Introduction    

Definition of Health: Health refers to the extent of a person´s physical, mental, and social well-being [1]. This World Health Organization (WHO) definition of health, emphasizes that health is a complex concept that involves not just the soundness of a person´s body, but also the state of a person´s mind and the quality of the social environment in which she or he lives, and has a cultural context to it [1]. The quality of the social environment in turn can affect a person´s physical and mental health, underscoring the importance of social factors for these twin aspects of our overall well-being [1]. More than a century ago, Rudolf Virchow noted that medicine is in essence a social science, and politics nothing more than medicine on a larger scale [2]. Virchow and many others over the past two centuries saw the extent to which disease and epidemics derived from the material conditions of living and the social stratification of society [2]. An enormous body of research and analysis confirmed this observation in relation to mortality as a whole and to a wide range of diseases and disabilities [2]. By the 1980s, many people from the National Institutes of Health (NIH) recognized the importance of social and behavioral research for their missions. The National Institute on Aging (NIA) for instance, promoted improved methodology and high-quality data to support substantive research across a wide range of issues affecting health, function, and well-being [2]. Similarly, the National Institute of Child Health and Human Development (NICHD) supported much sociological effort in the area of population research. While the heart, cancer, and other institutes were more narrowly focused, they increasingly supported epidemiological and behavioral research relevant to their categorical missions. The heart institute was particularly instrumental in developing the field of behavioral medicine [1].

The sociological approach to health: a sociological approach to health emphasizes that a society´s culture shapes its understanding of health and illness and practice of medicine [3]. In particular, culture shapes a society´s perceptions of what it means to be healthy or ill, the reasons to which it attributes illness, and the ways in which it tries to keep its members healthy and to cure those who are sick. Knowing about a society´s culture, therefore, helps us to understand how it perceives health and healing. By the same token, knowing about a society´s health and medicine helps us to understand important aspects of its culture [3]. A sociological approach to health examines rates of illness to explain why people from certain social backgrounds are more likely than those from others to become sick. Therefore, our social location in society-our social class, race and ethnicity, and gender makes a critical difference [3]. This approach aligns with Meikirch´s Model of One Health (Figure 1) which posits that: Health is a state of wellbeing emergent from conducive interactions between individuals' potentials, life's demands, and social and environmental determinants [4]. This conceptualization of the integrative nature of health contributes to ongoing efforts to strengthen cooperation across actors and sectors to improve individual and population health through One Health [4].

The ‘social determinants’ of health: these are the conditions in which people are born, grow, live, work and age, including the health system in which they have grown [5]. These things and circumstances are shaped by money distribution, power, and resources at all levels (global, national and local). They are responsible for health inequalities - between countries, between social classes, between genders. Responding to increasing worries about persisting and growing inequalities, the WHO established the Commission on Social Determinants of Health in 2005 to provide advice on how to reduce them. The commission´s final report launched in 2008, contained three umbrella recommendations: (1) Improve Daily Living Conditions, (2) Tackle the inequitable division of power, money and resources, and (3) Measure and understand the problem and assess the impact of action [5].

Society and the environment: the study of the environment by sociologists termed "environmental sociology", specifically refers to the study of the interaction between human behavior and the natural and physical environment [6]. Environmental sociology is important because environmental problems (1) are the result of human activity, (2) have a significant impact on people, (3) solutions to our environmental problems require changes in economic and environmental policies, and the potential impact of these changes depends heavily on social and political factors, (4) many environmental problems reflect and illustrate social inequality based on social class and on race and ethnicity: and as with many issues in our society, the poor often fare worse, and (5) efforts to improve the environment, often called the environmental movement, constitute a social movement [6]. Environmental sociology assumes “that humans are part of the environment and that the environment and society can only be fully understood in relation to each other” [7]. The American Sociological Association [8] reported that environmental sociology “has provided important insights” into such areas as public opinion about the environment, the influence of values on people´s environmental behavior, and inequality in the impact of environmental problems on communities and individuals. These environmental sociology assumptions align the One Health definition by the US Centers for Disease Control and Prevention (CDC) [9]. According to the CDC, the health of people is connected to the health of animals and the environment, and that One Health goal is to encourage collaborative efforts of multiple disciplines-working locally, nationally, and globally-to achieve the best health for people, animals, and our environment [9]. This paper describes the sociological approach to health and the relevance of this discipline to One Health using Social Construction Theories, and by describing the intersection of culture and health using case studies from the project “Capacity building in Integrated Management of Trans-boundary Animal Diseases and Zoonoses (CIMTRADZ)”, and beyond. Case studies of The Intersection of Culture and health are provided including the effect of cultural practices on brucellosis and tuberculosis (TB) in Uganda and Ebola spread in West Africa. The paper concludes by offering recommendations for the Way Forward including: (1) identifying ways in which African culture and healthcare intersect and impact global health security; (2) understanding how African beliefs and traditional practices impact on healthcare seeking behavior and attitudes within African communities, and (3) exploring ways in which to promote greater diversity in healthcare alternatives, by considering integration of African traditional medicinal practices towards greater global health security.

Methods     

Social construction theory: social construction is the way in which society groups individuals and provides certain privileges for one group over another [10]. Most people are unaware of social construction, as much of it takes place subconsciously. Points of differentiation in social construction include race, class and gender. The concept of social construction of reality is credited to Thomas Luckman and Peter Berger [10]. Social constructivism emphasizes the importance of culture and context in understanding what occurs in society and constructing knowledge based on this understanding [10].

Integrated sociological paradigm: Ritzer and Goodman (2004) [11] attempted to construct an Integrated Sociological Paradigm built upon two distinctions: between micro and macro levels, and between the objective and subjective (Figure 2). This paradigm produces four dimensions: macro-objective, large-scale material phenomena (such as bureaucracies); macro-subjective, large-scale ideational or nonmaterial phenomena (such as norms); micro-objective, small-scale material phenomena (such as patterns of behavior); and micro-subjective, small-scale ideational or nonmaterial phenomena (such as psychological states or the cognitive processes involved in "constructing" reality) (Figure 2). These dimensions are not conceptualized as dichotomies, but rather as continuums. Ritzer argues that these dimensions cannot be analyzed separately, and thus the dimensions are dialectically related, with no particular dimension necessarily privileged over any other [11].

Social Models of Health: Dahlgren and Whitehead (1991) [12] talk of the layers of influence on health. They describe a social ecological theory to health. They attempt to map the relationship between the individual, their environment and disease (Figure 3). Individuals are at the center with a set of fixed genes. Surrounding them are influences on health that can be modified. The first layer is personal behavior and ways of living that can promote or damage health; for example, choice to smoke or not. Individuals are affected by friendship patterns and the norms of their community (Figure 3). The next layer is social and community influences, which provide mutual support for members of the community in unfavorable conditions. But they can also provide no support or have a negative effect. The third layer includes structural factors: housing, working conditions, access to services, and provision of essential facilities (Figure 3). The social model of health takes a look at how factors in someone´s life, such as lifestyle, environment, and economic factors, will affect their health and their behavior towards taking risks and decisions made about their care. This gives a focus away from pathogens and biology to a look at someone´s living and working environment, their wealth, gender, race, and any other factors outside of the biological process.

The Intersection of culture and health: African culture generally prides itself on strong family ties, hospitality, and intra- and extra- community relations, where each individual household cares for its immediate and extended family members, for instance. Hugs and handshakes are common ways of greeting or expressing support and love for loved ones and acquaintances [13]. Another major aspect of the African culture is the rituals associated with burying the dead. This “proper burial” typically involves having extended family members and acquaintances of the deceased (which, in general, means pretty much all members of the local community) in very close proximity and contact with the corpse of the deceased, as people pay their last respects which they believe must be done in specific ways [13]. All the aforementioned constitute a cultural and traditional belief system and custom that are held in most African societies. These belief systems - particularly Africa´s culture of touching as a means of expressing natural support to sick loved ones - and the weakened healthcare system (and the absence of pharmaceutical intervention) provide the perfect breeding ground for epidemics to blossom as was the case in the 2014 Ebola outbreak in Guinea, Liberia and Sierra Leone [13]. These detrimental cultural belief systems and customs (particularly in the rural areas), do amplify the transmission of epidemics. This culture is embedded in a system in which the health-care system is, itself, weak due to factors such as poverty, famine, corruption, and, in some places, years of wars. Such factors (particularly corruption and wars) have led, in some cases, to mistrust of governments and people in authority.

Results     

The Intersection of culture and health - case studies

Case Study #1: Cultural practices and effect on Ebola spread: there is a strong belief that Ebola is contracted through a curse, or that it is a white man's fabrication, leading to mistrust of foreigners and associated humanitarian protective equipment, and to modern medicine as a whole. [14]. Ebola is one of the most virulent human viral diseases, with a case fatality ratio between 25 to 90% [13]. The 2014 West African outbreaks were the largest and worst Ebola outbreaks in history. There is no specific treatment or effective/safe vaccine against the disease. Hence, control efforts are restricted to basic public health preventive (non-pharmaceutical) measures. Such efforts are undermined by traditional/cultural belief systems and customs, characterized by general mistrust and skepticism against government efforts to combat the disease. Several studies [13, 14] determined that detrimental cultural belief systems and customs amplified the transmission of the Ebola disease in West Africa underscoring the roles of traditional customs and public healthcare systems on the disease spread. The principal nations caught in the Ebola crisis, namely, Guinea, Sierra Leone, and Liberia, had common challenges that complicated the effort to contain the disease; these included: high levels of poverty, weak state structures, and cultural beliefs about death and the after-life [15, 16]. Given the significance of containing such epidemics at the source, there is an urgent need to raise awareness and implement appropriate actions to address these challenges. It is critical, therefore, to involve sociologists to teach communities about taking basic precautions to prevent the spread of the disease, and isolating those who show symptoms so that they can be tested and treated. A sociological approach is required to re-address or abolish previously rooted traditional practices. Family members who come into contact with bodily fluids of Ebola patients in the process of nursing them, or those who hug or watch/touch the bodies of those who died from the disease at funerals, run a very high risk of contracting the disease and becoming themselves transmitters of the infection [15]. Other risk factors stemming from cultural practices include direct or indirect contact with great apes, through cooking or consumption of chimpanzee meat [17, 18], and a direct consequence of impoverished living conditions [19].

Case study #2: attitudes towards two major Zoonotic Diseases- Brucellosis and Tuberculosis control in Uganda: one of the key factors in preventing, controlling, and eradication of a disease from a given area and/or sub-population centers around changing human behavior. In order to affectively change human behavior, the social structure and culture of the community have to be considered. Communities have cultural beliefs and attitudes that may present a challenge to implementing, preventing, and controlling diseases. Two examples (provided in the next paragraph) illustrate the importance of understanding the attitudes and beliefs in disease prevention and control strategies. A study in Tanzania [20] reported that the majority of farmers believed that it was important to cook meat or boil milk to prevent brucellosis and TB. In contrast, the majority of the farmers´ perception of risk from handling infected animals or products was lacking. On the other hand, Holt et.al, (2011) [21] reported a higher knowledge of brucellosis among livestock owners in Egypt, although they still appeared to participate in high-risk behaviors. In a comprehensive study of zoonotic TB and brucellosis, Marcotty et.al (2009) [22] concluded that changes in the animal husbandry and behavior of the humans who live in at-risk communities is strongly indicated. Kazoora et.al, (2015) [23] indicated in their study in Uganda that overall knowledge and attitude towards zoonotic TB due to M. bovis was found to be very low. Additionally, Nasinyama et al (2014) [24] found that the consumption of un-pasteurized milk and milk products in two major cities (Mbarara and Kampala) in Uganda was prevalent. From the cited studies, it is very clear that one of the key strategies to reduce the prevalence and incidence of these major zoonotic diseases is to affect change in human behavior. In order to do so, socially and culturally acceptable strategies will need to be developed. Therefore, disciplines such as Sociology and Anthropology will need to be part of the One Health team to control these and other zoonotic diseases.

Case study #3: Anthrax outbreaks around Queen Elizabeth National Park, Uganda: sporadic anthrax outbreaks have occurred in and around Uganda's Queen Elizabeth National Park (QENP) for years, affecting wildlife, domestic animals, and humans [25]. Reported outbreaks (1959, 1962, 1991, 2004-2005 and 2010) in QENP collectively killed over 500 wild animals (hippos, zebras, buffaloes, warthogs, kobs, waterbucks, and elephants) and over 400 domestic animals [25, 26]. Subsequently, a 2011 outbreak in Sheema district temporarily froze local markets while killing two humans and seven bovines [27]. Investigations of these outbreaks sometimes focus on the effects of disease on animal and human health and not the surrounding ecological and cultural contexts [25]. Participatory methods connect problems (such as disease) to their context. A study [25] that used participatory epidemiology to investigate impact of anthrax on human livelihoods in the QENP area found that social pressures, the economics of poverty, and the lack of health and veterinary infrastructure significantly influenced responses to disease [25]. The complex connections between the social needs and the economic context of these communities seemed to be undermining current conventional anthrax control and education measures [25]. The livelihood-based decision-making of people around QENP was unlikely to respond to educational intervention alone; rather, the social pressures and the economics of poverty among the community need consideration in future anthrax control strategies.

Case study #4: social determinants of health among communities in Eastern Uganda centered on a mixture of religious and traditional beliefs: a study conducted by Higher Education Resource Services, East Africa [28] in Eastern Uganda identified beliefs among middle class groups, based on informal sharing of information, and centered on a mixture of religious and traditional beliefs. Association with church or devine intervention was regarded as a status symbol, where white-collar workers gathered for prayer and fellowship during the day, and Sunday services to seek joint answers to health matters and personal and professional development issues. However, some members from these same groups reverted to traditional systems during extended family events. During religious services and fellowship sessions, they exchanged the trendiest ideas and ‘new knowledge’ about a variety of issues including, but not limited to, preventative medicines, weight management, and treatments for a range of illnesses from mild (such as common colds) to life threatening conditions (such as cancer). At one such gathering, a woman spoke against routine cervical screening, arguing that it could accelerate the spread of cervical cancer. The applause she received, followed by (unreferenced) instant social media sharing of her message indicated that she had been believed without question, and her message was likely to impact any scientifically approved initiatives to encourage women to undergo cervical screening. In the study [28], the middle class had the capacity to make choices about foods from markets; they also had a tendency to self-diagnose illnesses and buy medicines from pharmacies. Additionally, there were reports from the local health centre of misdiagnosis of brucellosis as "malaria".

Case study #5: juxtaposition of nutrition and disease: in Uganda, culturally, use of insects as feed for poultry and or fish was not considered normal practice. However, hiking prices on poultry feeds, forced farmers to search for alternative feeds including use of insects for feed. Insects exhibiting swarming habits in Lake Victoria include mainly the Chironomidae, the Chaoboridae and Povilla adusta (Ephemeroptera) commonly called lake flies [29]. Adult swarming habits of lakeflies are closely correlated with lunar phases and the adults were easily trapped at night using kerosene lamps [29]. Biochemical tests of the nutrient value of lakeflies showed high levels of protein content (62%), minerals (18%), a low fat content (3.9%) and low moisture content (9%) [29]. This nutritional profile makes lakeflies ideal as additives in animal feeds for poultry and aquaculture fish [29]. Interestingly, in Nyanza Province, Kenya within the Lake Victoria region, lakeflies are consumed and also used for other cultural purposes [30]. Some traditional medicine practitioners add the fly powder to their concoctions to cure certain ailments. They claim that the fly powder enhances efficacy of herbal medicines [30]. Subsequent research to test the suitability of lakeflies as an ingredient in animal feeds allowed insects to be considered by rural and urban farmers in Uganda as source of protein in poultry and fish feed.

Discussion     

In much of Africa, beliefs, religion, and traditional medicine have historically gone hand in hand, but increasingly these elements have come into conflict with modern healthcare which is secular in nature and more heavily challenged. For instance, it is estimated that about 70-80% of the population in developing countries depends on traditional medicine for their primary health care needs [14]. African healers often ask ‘why are you ill?’ as well as ‘what is wrong?’ In fact many traditional healers, after consulting their ‘ancestors’ and ‘spirits’, pre-empt what is wrong with the patient, over and above what the patient might believe to be wrong. Most African cultures equate silence with respect. They also inculcate respect for elders, in particular, traditional healers; in this regard, therefore, what the traditional healer says cannot be questioned; moreover, ‘asking questions’ is often interpreted as ‘questioning’. This means that the traditional healer´s diagnosis, prescription and prognosis are accepted, and take precedence over Western scientific approaches to health and wellbeing. In his study on social constructions of water safety and risk in Uganda´s capital city Kampala, Batega (2012) [31] observed that “the social constructions of water safety and risk influenced water use and adoption of mitigation and abatement measurers”. The study [31] highlights tensions between scientific information and cultural beliefs about sources of safe water. In 2015 Water.org estimated that 8.4 million Ugandans did not have access to safe water, and in rural areas, the main sources of drinking water include rivers, swamps, and lakes, of which Uganda is well endowed. Meanwhile, waterborne diseases such as bacterial diarrhea, hepatitis A, and cholera are not uncommon, and in 2013 Uganda´s Ministry of Health reported cholera outbreaks in three districts (Nebbi, Buliisa & Hoima) along Lake Albert affecting nearly 1 million people. Mitigating such outbreaks requires careful understanding of cultural perceptions which range from reverence of water (possessing varying magical powers) to inculcated generational beliefs about taste, flavor and safety of natural water sources compared to piped water, which is viewed with suspicion by some social groups. Batega concluded that “ ...improving access to safe water sources through the expansion of tap water systems and price regulation is essential but not sufficient without addressing the embedded nature of community social constructions of water safety” [31].

WHO recognizes that healthy ecosystems are essential for maintaining human health, yet, around the world, collapsing ecosystems pose increasing risks for human health [32], due in part to the widespread consideration of ecological restoration as a “long-term objective”, while continued anthropogenic stress continues to degrade the Earth´s natural ecosystems. Further, efforts to counter the prospect of an avian influenza pandemic have been centered on the short term - namely on “fixing the problem”, rather than preventing the factors that first led to its emergence [32]. For instance, there is growing concern that a highly pathogenic strain of avian influenza, HPAI H5N1, could spark the next influenza pandemic, with a toll of millions of human lives. Vaccines for poultry, culls in outbreak areas, limitations on trade flows are control measures used in outbreaks. Stockpiling of potential anti-viral medicines, heightened surveillance, and emergency preparedness are prudent measures to minimize human casualties should a pandemic arise. Left out of the equation for the most part, however, are preparations to redress ecological imbalances that have given rise to the threat in the first-place. This gap calls for adopting an ecohealth perspective - one that focuses on the upstream causes of emerging diseases, which are at root questions of ecosystem degradation and ecological imbalance. Restoring health to the world´s ecosystems is an essential aspect of the struggle to reduce human vulnerability to emerging and resurging diseases [32].

Conclusion     

This paper recognizes the importance of cultural beliefs, religion and traditional medicine in much of Africa, and how these practices conflict with modern healthcare. This underscores the urgent need to: (1) identify ways in which African culture and healthcare intersect and impact global health security, (2) understand how African culture impacts healthcare seeking behavior and attitudes within African communities, and (3) explore ways to promote greater diversity in healthcare alternatives, by considering integration of African traditional medicinal practices towards greater global health security.

Competing interests     

The authors declare no competing interest.

Authors´ contributions     

All authors contributed to development and design of the paper, writing the article, and intellectual content. All authors reviewed several drafts, and approved the version to be published.

Acknowledgments     

The authors are grateful for the United States Agency for International Development (USAID) funding under The Africa-US Higher Education Initiative through the CIMTRADZ project and the invaluable contribution of the CIMTRADZ partner institutions in East and Central Africa, the United States, particularly Mississippi State University and Michigan State University, as well as Makerere University in Uganda, and Higher Education Resource Services, East Africa.

Figures     

Figure 1: the Meikirch Model of Health: health occurs when individuals use their biologically given and personally acquired potentials to manage the demands of life in a way that promotes well-being; this process continues throughout life and is embedded within related social and environmental determinants of health; health is constituted by all three dimensions - individual, social, and environmental determinants of health. Source: [Birchera J., and S. Kuruvilla, 2014]

Figure 2: Ritzer´s integrative (micro-macro) theory of social analysis. Source: Ritzer G. and D.J. Goodman. Modern Sociological Theory; 6th Edition, 2004. Chapter 10, pp315; The McGraw-Hill Companies, Inc, 1221 Avenue of The Americas, New York, NY, 10020

Figure 3: the Dalghren-Whitehead Social Model of Health. Source: Dalghren G., and M. Whitehead, 1991; Policies and Strategies to Promote Social Equity in Health. Stockholm, Sweden: Institute for Futures Studies

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