The role of sociocultural influences in the origin, incidence and prevalence of specific diseases, especially among ethnic or racial minorities and divergent cultures cannot be disregarded in health related research investigations. With regard to political health and healing, the sociocultural aspect is critical in ensuring a positive outcome of public health programs disseminated in intercultural settings owing to the impacts of the cultural gap on communication of innovative solutions and their selective acceptance by the target population (Lynch 1975). The cultural gap is directly related to the culturally conditioned assumptions on the causes of various illnesses.
The emergence of cultural interpretive approach as an integral component of medical anthropology is a direct response to the past dominance of ecological perspectives in the arena of health and disease. In context, ecological perspectives posit that disease be treated as a component of nature, hence external to culture. Contrarily, the cultural interpretive theoretical model posits that disease in itself does not qualify to be an entity of nature but rather an explanatory model. In essence, disease belongs to the cultural underpinnings and with specificity, to the culture of medicine. Culture serves not only as a means of disease representation but also as an essentiality in the very constitution of human reality (Baer et al 2003). The cultural perspective of disease is usually known by both the healers and the sufferers alike through a set of unique and distinct interpretive activities which involve an interaction of the biological component of disease with social practices as well as the constituted cultural frames of meaning. These interactions directly influence the construction of clinical realities.
Kwashiorkor cannot exclusively be dietary in aetiology because infective, cultural and psychological and several other conditioning factors have been demonstrated to singly or in combination with the dietary aetiology, influence the incidence and prevalence of the disease. Definitively, as a disorder of nutrition, kwashiorkor occurs due to severe protein deficiency even if the calorie intake is adequate. In areas where the nutritional disorder is endemic, it often afflicts children subsequent to weaning. Diagnostically, the disease is characterized by muscle wasting, growth retardation, swollen abdomen, edema, hair loss, anemia, dry hyper pigmented lesions on the face, perineum and the extremities. Such children are also anorexic and lethargic and may also exhibit signs of hypothermia, bradychardia, decreased blood pressure and increased risk to cardiac failures. Kwashiorkor is a fatal disease and approximately 40% of children affected die even in the presence of medical intervention.
Even though kwashiorkor is a disease primarily caused by protein deficiency, hence its prevalence in underdeveloped and technologically disadvantaged regions, an analysis of the incidence and the prevalence of kwashiorkor among regions with equally limited food resources yield very variable results. This implies that the differences in weaning and other culturally conditioned assumptions that determine the suitability of certain nutriments in the post weaning period play a fundamental role in the incidence and prevalence of the nutritional disorder. Some studies have also demonstrated that parental indifference and solitude may also be involved. These psychological factors serve as examples of dispositions that are partly a consequence of cultural conditioning (Lynch 1975).
Since man is a sociocultural animal, the roles of culture and social values in defining the causes, susceptibility and response to kwashiorkor cannot be underestimated (Lynch 1975). In a study done in Cameroon, Robert Pool reported on the connection between the prevalence of kwashiorkor and the sociocultural factors. The illness was particularly prevalent in the village despite the presence of adequate food supplies. In such a scenario it was only reasonable that the prevalence could be attributed to other factors other than the inadequacy of food. In discussions with the villagers, there was virtually no mention of malnutrition even though it is the medically known etiological factor behind kwashiorkor. In fact, the illness was attributed to moral faults of the ancestors or the parents of the children. Such moral faults included; suicide, murder and incest. Some attributed the illness to witches. Thus, the medical term ‘kwashiorkor’ was only used as an imported terminology referring to an age old problem that was in no circumstance related to nutritional deficiency. As a result, health campaigns and treatment programs bore limited success (Van Den Borne 2005).
This represents a classic example of a sociocultural interpretation of an illness even if such an interpretation is in direct opposition to the biomedical fact. In the social or cultural context, illness is a cultural product and a social event. As a cultural product, “it is impossible to think of it in such a way that it is totally unrelated or meaningless to the life of the patient”. As a social event, “the pain and the symptoms are made known to others in a socially acquired way”. Therefore, “a patient who does not abide by the cultural rules runs the risk of being misheard and will not receive the support and sympathy that he hoped for” (Van Den Borne 2005, p. 12). The explanation of illness by the patient or the healer/health worker is viewed as a cultural act. In cases where a definitive cause cannot be found due to the paucity of scientific data, the society draws such causative explanations from social causes like jealousy which can exhibit as evil eye or witchcraft.
Since the majority of children affected by kwashiorkor; approximately 20%, a classic study of the cultural interpretive theory in medical anthropology can be drawn from a study of kwashiorkor in Ghana where the nutritional deficiency diseases are ranked the sixth leading cause of death among children under the age of five. Kwashiorkor is responsible for more than 50% of these deaths. Children who survive are predisposed to long term complications such as physical stunting (Douglass et al 2007).
Even in urban Ghana, the problem remains endemic despite the availability of food. Therefore, to understand the factors behind the persistent endemicity, it is prudent to carry out a detailed analysis of the sociocultural underpinnings that may be responsible for the high number of kwashiorkor cases. Currently in Ghana, food is not in shortage, protein rich foods originating from the Bay of Guinea continue to flood the urban markets. This implies that despite the fact that absence of sufficient nutritious food, usually due to abject poverty, causes kwashiorkor cases of childhood malnutrition in the urban centers and the neighborhoods deserves a much more complicated understanding because food is generally sufficiently available(Douglass et al 2007).
Douglass et al(2007), reported in a study done between January 1999-June 2003 that the continuing endemicity of the disease in urban Accra is a reflection of the social customs, norms, gender and age discrimination coupled to poverty and the inadequacy low literacy levels especially on nutritional needs of children. In some cases the presence of twins or maternal illness has also been responsible for the high number of cases. Nutritionally, other substitutes for the mothers milk like egg concoctions have been frowned upon because it is believed that such substitutes cause severe diarrhea in children.
Some cultural factors within the greater family set-up deny these children access to protein rich foods and a host of other micronutrients that are important for normal growth and development. From a socio clinical perspective, the disease is frustrating to detect because such children are usually quiet, passive and not agitated. These are not attributes that are usually associated with starving children. Moreover, the full, sometimes bloated belly is often confused by the mothers as normal. It is very difficult to convince such mothers that a bloated belly can be a symptom of malnutrition. The classical red hair rather than being viewed as a medical problem is instead viewed as an embarrassment to the family. In extreme cases such hair is masked by any black agent such as shoe polish. By masking these apparent symptoms of kwashiorkor, these children gradually deteriorate in health to a point when any medical intervention becomes ineffective in reversing the effects of the disease(Douglass et al 2007). If the child survives, they have to face the prospect of permanent physical disability or stunting.
The study also demonstrated that in some very traditional homes, the cultural norms directly lead to kwashiorkor among the children. For instance, the oldest men are culturally given the privilege to access the fish, meat or fat first before any other members of the family does so. In certain situations, these old men may conclude their meals even before the mothers and children begin eating. This has created a scenario in which even though the protein foods are readily available, the mothers and the children virtually have no or little access to them. Continually putting children at the bottom of the familial food chain is directly responsible for the development of the protein deficiency disorder. Given that women have been socially conditioned to feed the older men first, any intervention that does not take this fact into perspective is likely to achieve nothing. Therefore culturally sensitive public health education is key to reducing the endemicity. As Douglass et al(2007) puts it, “pediatric deaths from kwashiorkor are largely preventable, this is not a problem of poverty; it is caused by a poverty of knowledge”(Douglass et al 2007, p. 11).
These results attest that when investigations of diseases are carried out in underdeveloped and generally neighborhoods of a low socioeconomic status, it is unwise to condense the application of the measures of mitigation to practicality and circumstance alone. By accepting that malnutrition disorders like kwashiorkor have persisted despite serious public education efforts, an extra stride should be made to reconcile the relevant cultural and social factors that have an effect on disease and health on the models of interventions proposed. It is upon these sociocultural definitions and response to disease that profoundly influence any form of medical intervention. In most cases, public health programs fail to meet the targeted outcome because, such strategies fail to include the social and cultural concept of illness and disease in the dissemination of nutritional or preventative programs aimed at improving childhood health.
Baer, H.A., Singer, M., Susser, I. (2003). Medical anthropology and the world system. 2nd Edition. Greenwood Publishing Group, 36-38.
Douglass, R. L., McGadney-Douglass, B. F., Antwi, P., Apt, N. A. (2007). Filial Factors of Kwashiorkor Survival in Urban Ghana: Rediscovering the Roles of the Extended Family. African Journal of Food Agriculture Nutrition and Development. Vol 7(1); 1-16
Lynch, L. R. (1975). Cross-Cultural Approach to Health Behavior. Fairleigh Dickinson University Press, 28-29.
Van Den Borne, F. (2005). Trying to Survive in Times of Poverty and AIDS:: Women and Multiple Partner Sex in Malawi. Het Spinhuis, 11-14.