Anda di halaman 1dari 9



So-called ‘diseases of lifestyle’ are playing a Philip W. Setel, PhD
major role in epidemiological transitions in
many developing countries. Stratifying, urban-
izing, and ageing African populations face ris-
ing levels of non-communicable diseases
(NCDs). This article examines the need for an-
thropological perspectives on the causes, pre- EVOLVING HEALTH developing countries, and in the Africa
vention, and control of NCDs, such as diabetes DEVELOPMENT PRIORITIES region in particular.10–12 The aim is to
and hypertension, in Africa. Anthropologists
have been silent on these topics in African
IN AFRICA enhance ‘‘the capacity of countries to re-
public health for a decade or more. Commu- duce significantly the burden of NCDs
nity-oriented field studies on structural and so- and improve the quality of life and life
cio-cultural aspects of NCDs are urgently During the 1990s, it became appar- expectancy . . . through the efficient
needed. There can be little doubt of the ben- ent that non-communicable diseases prevention and control of NCDs.’’12
efits to be gained from a multi-disciplinary ap- (NCDs) were playing a much more This will be accomplished through:
proach to NCD study and intervention for de- prominent part in African population
veloping countries. However, key institutions
and health transitions than previously 1. improved epidemiological sur-
setting the research agenda are doing so with-
out the input of anthropologists or social epi- thought.1,2 By 1990, for example, at veillance;
demiologists, and without an emphasis on so- least half of all people suffering from di- 2. a major emphasis on communi-
cial science capacity strengthening in African abetes (more than 25 million) lived in ty-based programs of risk reduc-
countries. (Ethn Dis. 2003;13[suppl2]:S2-149– tion;
developing countries.3 In East Africa,
increased rates of NCDs have been 3. the dissemination of low-cost
Key Words: Non-Communicable Diseases, linked to social change and develop- case management and NCD con-
Cross-Cultural Comparisons, Anthropology, Af- ment, rapid urbanization, and overall trol; and
rica South of the Sahara population ageing.3,4 One source has 4. increased capacity of developing-
concluded that in the United Republic country institutions to undertake
of Tanzania, hypertension already plays research to inform decision mak-
an important underlying role in mor- ing.
tality, even in rural areas.5 The question then arises: which of
Combating communicable diseases the various disciplinary resources in in-
such as HIV/AIDS, malaria, and diar- ternational health are best situated to
rhea, clearly must remain the top pri- contribute to accomplishing this agen-
ority for improving the health of the da? This article argues for the early in-
world’s poorest citizens.6,7 Nevertheless, clusion of anthropologists in its forma-
the reality is that rates of preventable tion and attainment. The focus is on
NCDs in poor countries have been es- hypertension, heart disease, and diabetes
calating rapidly. The 1990 Global Bur- as NCDs of escalating importance in
den of Disease study predicted that the African context. It should be noted
within the next 20 years sub-Saharan that these conditions are not the only
Africa will experience greater increases non-communicable conditions of public
in NCD morbidity and mortality than health importance on the continent.
any other region of the world.2 This Unipolar major depression, for example,
suggests that the globalization of con- is predicted to become the single largest
sumption patterns and lifestyle changes cause of disability-adjusted life years
From the Adult Morbidity and Mortality
is introducing a new and complex di- (DALYs) lost globally, and to dramati-
Project, Tanzanian Ministry of Health and mension into Africa’s poverty/disease/ cally increase in importance in sub-Sa-
School of Clinical Medical Sciences, Uni- health development nexus which cannot haran Africa early in the twenty-first
versity of Newcastle upon Tyne, UK. reasonably remain un-addressed by the century. 13 In contrast to mental
international health community.8,9 health,14–16 however, hypertension and
Address correspondence to Philip W.
Setel, PhD; AMMP; PO Box 65243; Dar es
In response to these challenges, the diabetes in Africa have been virtually
Salaam; Tanzania; 1255 22 215 3388; 1255 international health community recently unexamined by anthropologists and
22 215 3385; set an agenda for confronting NCDs in other social scientists.

Ethnicity & Disease, Volume 13, Spring 2003 S2-149


Table 1. Some areas amendable to anthropological research and intervention in

The 1990 Global Burden of NCDs in Africa
Disease study predicted that Culture change
Explanatory models of emerging chronic diseases
within the next 20 years Belief systems and social structures affecting tobacco and alcohol use
Diet and obesity
sub-Saharan Africa will Exercise
Genetic, behavioral, and psychosocial adaptation
experience greater increases in Health beliefs
Development of empirical and culturally appropriate ‘lifestyle’ and ‘stress’ concepts
NCD morbidity and Socio-economic status and poverty
mortality than any other Cost-effective interventions
Improved epidemiological surveillance of health education
region of the world.2 Patient-focused and home-/household-based programs of disease management and care

tory, political economy, gender, and cul- that includes an anthropological per-
A LACK OF ENGAGEMENT tural beliefs about the nature of good spective would seem an obvious course
IN THE AFRICAN CONTEXT and ill health cut across everything from to adopt. Anthropologists should in-
designing improved epidemiological volve themselves in the early stages of
In the African context, key concep- surveillance of NCDs to health educa- this emerging effort rather than waiting
tual questions must be asked about the tion and the design of cost-effective to be called on to explain failures and
social and cultural determinants, man- health services. unintended consequences of well-inten-
agement, meaning, and impact of Experience from the North in NCD tioned but imperfectly conceived pro-
emerging NCDs. A search of several on- prevention has shown that expensive grams, as has too often been the case in
line databases using combinations of community-based initiatives for risk be- the past. The sub-fields of cultural,
MESH search terms such as ‘‘cross-cul- havior modification have generally medical, nutritional, and demographic
tural comparison,’’ ‘‘anthropology,’’ ‘‘hy- failed, or met with only modest suc- anthropology and human behavioral
pertension,’’ ‘‘blood pressure,’’ and ‘‘di- cess.21 This includes at least one inter- ecology can bring vital perspectives to
abetes,’’ yielded no significant research vention with a cross-cultural focus, both applied and theoretical problems
on social and cultural aspects of NCDs which included the participation of tar- in confronting the determinants of
such as hypertension and diabetes in Af- get communities in design and control NCDs in Africa (Table 1), as they have
rica for at least 10 years. To date, an- strategies.22 A variety of factors may ac- for infectious diseases, including malar-
thropologists who have engaged in the count for the lack of significant mea- ia, diarrhea, and HIV/AIDS.24–27 As one
escalating discussion about globalization surable progress. However, those in- review of epidemiological and anthro-
and health inequalities have failed to en- volved in community intervention stud- pological evidence on hypertension ar-
gage these issues as they pertain to com- ies have concluded that ‘‘they may have gued almost 20 years ago, ‘‘socio-cultur-
mon NCDs.17,18 Thus, this new agenda’s under-estimated the complexity of com- al influences should be the predominant
lack of a social science perspective, and, munity dynamics, the intricacies of for- focus and concern of public health.’’28
more specifically, an anthropological mal, as well as informal, community In the African context this call has yet
one, is not solely due to lack of inter- structures, and countervailing societal to be answered.
disciplinary spirit on the part of agenda- and economic forces . . . Obviously, we Although it is beyond the scope of
setters. need a much better understanding of this article to include an extensive re-
In Africa, as elsewhere, confronting community forces that influence view of contributions made by social
the context of risk in which NCDs are change.’’23 If this concern can be raised scientists, and anthropologists in partic-
taking hold will be central to the success for community-based approaches in de- ular, to NCD work in developing coun-
of the international health agenda as veloped countries after decades of plan- tries outside of sub-Saharan Africa, even
outlined above. Understanding the so- ning and effort (not to mention tens of a basic familiarity with these fields
cial and cultural basis of health, healing, millions of dollars in research funds), should be adequate to begin the dia-
and population change in Africa will be clearly it can be addressed at this com- logue. The remainder of this article be-
no less central to these public health paratively early stage with respect to de- gins such a discussion; it does not claim
challenges than it has been in the veloping-country NCD initiatives. to be an extensive review, or to treat
past.19,20 Contextual forces, such as his- Therefore, a multi-disciplinary effort comprehensively any of the many com-

S2-150 Ethnicity & Disease, Volume 13, Spring 2003


plex issues raised. (For a review of an- trast, would encompass structural and pological approach to NCD (albeit
thropological studies of hypertension, social vulnerabilities, as well as biologi- greatly simplified) concurs with recent
see Dressler’s recent contribution.29) cal and behavioral ones. Within such a theoretical frameworks for globalization
health transition perspective, anthropol- as well as health and social epidemiol-
ogists would draw a wide circle around ogy.
A HOLISTIC APPROACH IS the notion of ‘risk’ and ‘risk factors.’ In Culture is often evoked as a reason
REQUIRED particular, they would explore how the for the failure of interventions, or as an
rise of NCD risk reflects the changing obstacle to their success; however, even
social and economic position of certain in contemporary theoretical frame-
Social anthropologists and social ep-
groups and individuals relative to other works, the concept fails even to gain a
idemiologists adopt a ‘holistic’ approach
members of society. In this model of mention.39,40 Without the more active
to phenomena under study, believing
risk, structural, environmental, and in- engagement of anthropologists in the
that the wider cultural, social, political,
dividual forces would all receive consid- area of public health praxis, the culture
economic, and historical context sur-
eration in the design of NCD interven- concept—a key element of context—
rounding the rise of any disease is im-
tion and policy. This holistic ‘upstream’ will remain under-theorized, a ghost in
portant to its full understanding. Med-
view, which is fundamental to public the machine that will hamper profes-
ical and demographic anthropologists
health, has yet to be widely applied to sional understanding of the manifesta-
usually include local disease ecologies
NCD work in Africa. tions of conditions of interest, and ways
and demographic conditions, as well as
Early cross-cultural comparisons of to address their root causes. A brief ex-
major determinants of health (such as
blood pressure and socioeconomic sta- ample follows.
social and economic stratification), in
this holistic view. Social, cultural, polit- tus, for example, suggested that risk
ical, and economic forces are also woven could fruitfully be explored through ex-
into the health system itself, encom- amining variables such as ‘level of en- RISK AND AFRICAN
passing the relationship between pa- gagement with cash economies,’ or ‘lev- ‘MALADAPTATION’
tients, families, and medical practition- els of economic competition.’35 As one
ers, whether they be ‘modern’ or ‘tradi- study of social status and blood pressure Implicit theories of culture pervade
tional.’20,30,31 in the Caribbean concluded, ‘‘linkages the epidemiological literature. Most of
Many epidemiologists and anthro- and interactions between the macro and those familiar with contemporary re-
pologists would see the rise of NCDs as micro need to be incorporated system- search on AIDS, in particular, are at
rooted in health transitions, and share atically into the rapprochement of po- least sensitive to this concern. There is
the basic premise that such transitions litical-economy and human biology.’’36 a strand of the AIDS literature that is
are shaped locally by rates of fertility Expressed another way, anthropologists both relevant to NCDs and illustrative
change, the distribution of risk factors, should seek to understand how global- of the need for anthropological engage-
and by the health system’s responsive- ization, local economic development, ment; this strand concerns ideas about
ness.32 Risk, a malleable concept in ep- and urbanization, change the basic con- culture change and adaptation to mo-
idemiology,33 is usually defined in terms ditions of day-to-day life for certain dernity.41 The example may be apt, giv-
of variables associated with individual groups in society. These factors influ- en that AIDS is not only a chronic dis-
vulnerability. Many social scientists have ence such mundane practices as what ease, it has often been portrayed (like
criticized this as conceptual reduction- people eat, how they get exercise, and some NCDs) by both international
ism, terming it the ‘epidemiological fal- what non-food substances they use—all health experts and local populations in
lacy.’ Epidemiologists studying deter- of which affect risks of developing con- Africa as ‘a disease of development.’41,42
minants of cardiovascular disease in Eu- ditions such as hypertension, diabetes, The oversimplification of African adap-
rope and North America are increasingly or heart disease, as well as affecting how tation to modern life was evident in the
adopting analytical techniques that al- people respond to falling ill. In the models of epidemiological risk and con-
low for multiple and hierarchical levels study of HIV/AIDS in Africa, this ap- trol that dominated the scientific un-
of variation (such as multi-level model- proach has sometimes been called ‘eco- derstanding of AIDS for nearly a de-
ing). This is an implicit acknowledg- logical’ or ‘environmental.’37,38 Ecology cade.43
ment of the need to redress reduction- also serves as a ‘master’ metaphor for These models were based upon naive
istic concepts of risk, and represents ap- some current directions in social epide- assumptions about African sexual beliefs
proaches to quantitative data to do so. miological theory.39 With the concept of and practices. In this regard, epidemi-
A more anthropological or social ep- culture being the only major exception, ologists tended to portray risk in 2 dif-
idemiological concept of risk,34 by con- the foregoing summation of an anthro- ferent ways: as either a matter of indi-

Ethnicity & Disease, Volume 13, Spring 2003 S2-151


vidual choice in adopting protective be- may become embedded in the conven- prevention and control. Some familiar
haviors, such as condom use or partner tional epidemiological wisdom about concerns about anthropology in public
reduction, or as group vulnerability re- NCDs among Africans (or Americans of health are that ‘traditional’ ethnographic
sulting from maladaptation to modern African descent54), as they did in the research takes too long, rarely points to
urban environments.44,45 case of AIDS. clear therapeutic or preventive interven-
Anthropologists and historians were It is dangerous to apply a naive mal- tions, and is usually too culturally or
quick to point out that this latter for- adaptationist cultural theory to research geographically specific to be generaliz-
mulation of epidemiological risk and on NCDs and risk in health transitions able. Again, the experience of anthro-
vulnerability was antiquated. Since the in Africa because, as seen with the study pological involvement in confronting
colonial era, ‘culture’ in the village con- of AIDS, such a theory neglects to in- AIDS should lay most of these concerns
text was seen as a reactionary set of be- clude a thorough assessment of social to rest. 58–63 Further, as research on
liefs hindering development, holding structures and meaning. These are issues NCDs from non-African settings has
people back from becoming modern.46–49 that have proved central to understand- demonstrated, anthropologists can col-
Culture was also viewed as a reservoir of ing health and illness in Western set- laborate effectively, both in model
medical misconceptions, making com- tings. In the case of AIDS, these issues building and hypothesis generation, and
munities resistant to healthful change. have been explored most extensively in in the design and evaluation of inter-
However, when Africans made the jump health transition,19 or ‘culture and po- ventions. Researchers in the Americas
to ‘modern’ settings, such as cities and litical economy,’ approaches.55–57 have produced a growing literature on
industries, medical researchers perverse- This is not to say that studies of ad- cultural and contextual aspects of
ly denigrated or pitied them for having aptation and modernization should be NCD-related belief and behavior. A
‘abandoned’ or ‘lost’ their culture, a excluded from the agenda; however, great deal of this work has been con-
state that rendered them more vulnera- they must be framed with theoretical ducted among disadvantaged or margin-
ble to disease.48 rigor. Within anthropology, the sub- alized populations, including American
Since at least the mid-1900s, Afri- field of human behavioral ecology, for Indians in the United States, Canada,
cans were seen, in an epidemiological example, can help refine the concept of and the Caribbean.22,29,36,64–80
context, as being stranded in a concep- adaptation as it relates to modern set-
tual no-man’s land between modernity tings and NCD risk. Propositions that Explanatory Models and
and tradition without a clear set of prin- ‘‘the anthropological evidence . . . [sug- Qualitative Research on the
ciples that might protect them from the gests] . . . that human maladaptations in Experience of NCD
unhealthy risks of living in cities and affluent society are due to a dissonance One of the most common ways an-
participating in wage labor econo- between the modern culture and the thropology has been used to improve
mies.47,50,51 As an extension of this sim- evolutionary legacy’’28 may, thereby, be the design of NCD care in non-African
ple view of adaptation, concepts such as framed as testable hypotheses and inves- settings has been the application of
‘urban’ vs ‘rural,’ or ‘modern/Western’ vs tigated as such. When reinforced by Kleinman’s concept of ‘explanatory
‘traditional,’ were juxtaposed as if they careful ethnographic research, concepts models.’81 The study of explanatory
were clear-cut dichotomous variables, of modernization, stress, and adapta- models, or ‘cognitive domains,’ of illness
when they were not.52 tion, have offered useful insights into has been part of medical anthropology
These concepts persisted into the era NCDs in the Americas and Samoa.29 since the 1980s. These terms refer to
of AIDS research and control, covering Such approaches could be extended to concise statements of illness beliefs,
too much conceptual territory with too research in sub-Saharan Africa. from both professional and lay sources,
little sociological rigor. They have collected using ethnographic or quali-
played such a predominant role in West- tative methods. They have been pro-
ern studies of change in population
APPLICATIONS OF posed as standard techniques for clinical
health in Africa, that African clinicians
ANTHROPOLOGY TO NCD NCD work in the United States,82,83
and epidemiologists have begun to ap-
PREVENTION AND and standard methods for utilizing them
ply them to NCDs. ‘‘If one considers
CONTROL to conduct comparative work in inter-
ecological urbanity as a continuum from national health have been developed.84
rural to urban, the information obtained A cultural and political economy ap- Despite their widespread applica-
therefrom supports the thesis that proach is central to understanding the tion, we know almost nothing about lo-
[chronic heart disease] is a function of root conditions of NCD transitions and cal concepts and self-perceptions of
Westernization or social sophistica- structural risk in Africa; however, an- NCDs such as hypertension and diabe-
tion.’’53 If left unchallenged, these views thropology can also contribute to NCD tes among Africans, or about explana-

S2-152 Ethnicity & Disease, Volume 13, Spring 2003


tory models and beliefs regarding etiol- variations in blood pressure.89 More nu- sponses to chronic stress, and to change
ogy. Nor do we have information about anced understandings of adaptive strat- in social status, among both humans,
how gender informs the experience of egies and coping in the complex world and non-human primates.90–92 While
these illnesses; treatment seeking in the of South African apartheid were re- not of immediate impact for primary
context of plural healthcare systems; quired. prevention or control, these areas of re-
concepts and practices of local provid- Dressler and colleagues have devel- search may soon point to pathways that
ers; and long-term household or family oped the lifestyle concept in research on mediate physical responses to stress in
impact and coping strategies. socio-economic and cultural dimensions conditions of relative and absolute dep-
The study of explanatory beliefs of hypertension in the Americas.29,36,65–69 rivation. This, in turn, might some day
about NCD causes and care also offers This has entailed the measurement of help to explain how NCDs can become
opportunities for addressing the patient/ ‘lifestyle incongruity,’ a model in which burdening diseases of the poor, as well
practitioner relationship. This will be individual differences in social and psy- as the rich.
important to both improving clinical chological characteristics are related to
medical services, and to working with large-scale processes. Their aim is to Locus of Control and NCDs
traditional healers, who are often in a connect upstream forces with down- A common hypothesis is that those
better position than clinicians to pro- stream outcomes in a way that is both who perceive the cause and course of
vide more psycho-social support in the biologically and sociologically plausi- their illness to lie beyond their personal
NCD context.85 In an era of rapid de- ble.36 influence may adhere poorly to treat-
velopment and social change, cultural As an extension of concepts of ment; however, the theory was tested
meanings and behavioral patterns asso- changing lifestyle and stress, social co- cross-culturally in the area of diabetes
ciated with good health, as well with ill hesion is also relevant in assessing risk with inconclusive results.93 This notion
health and disease management also will of NCDs in rapidly changing develop- of ‘locus of control’ has been applied in
change. Indeed, anthropologists have ing country settings. A breakdown of clinical anthropology in the United
documented ways in which the most perceived levels of social cohesion may States, and in cross-cultural research on
fundamental ideas about the human relate to both NCDs, and to an in- both diabetes and hypertension.72,78,82,83
body are informed by cultural values, creased sense of vulnerability to forces A group in Yugoslavia, for example,
thereby changing over time.86–88 beyond the individual’s control.72 For worked to strengthen the sense of social
example, social class differences in blood support for elderly people with hyper-
Development of Lifestyle and pressure among Jamaicans were medi- tension.94 They identified culturally rel-
Stress Concepts ated by perceived levels of social support evant institutions upon which to style
The concepts of ‘lifestyle’ and for men, and by economic stress for their efforts, and the resulting self-help
‘stress,’ like those of culture and risk, are women.69 groups met with some success. This ap-
poorly operationalized in the developing The exact pathways by which stress, proach may be an extremely important
country NCD literature of the maladap- lifestyle incongruity, lack of social co- one in the African context. Many cul-
tative viewpoint, and so are of limited hesion, or relative powerlessness, might tural theories of disease causation in Af-
utility. As with ‘culture,’ the lifestyle lead to the development of chronic dis- rica locate the etiology of sickness, at
concept often functions as a catch-all eases are not understood. Concepts such least in part, as being beyond individual
category for a set of risk factors assumed as ‘alostasis’ and ‘alostatic load’ refer in control. Thus, at a simple level, one
to be interconnected, and to relate to a general sense to the toll taken on spe- may hypothesize that in social settings
some imagined scale of modernity. Po- cific bodily systems due to chronic over- where illness causation is strongly asso-
litical economy and powerlessness cross- or under-stimulation. Such attempts to ciated with the malevolent actions of
cut these ideas implicitly; we need to locate and measure the ways in which others it may be difficult to motivate
make these concepts more explicit, em- social and cultural stresses can be di- wide-scale preventive behaviors or to
pirical, and measurable. These risk fac- rectly linked to pathological outcomes, sustain participation in treatment plans
tors include urban residence, strained even to pinpoint the physiological pro- or self-care initiatives.
social or kinship networks, lower levels cesses that mediate between body sys-
of physical activity, greater likelihood of tems and environment in this way, need Nutritional Anthropology
cigarette smoking, or consumption of a great deal of theoretical development Research on diet and nutrition are
fatty food. Since 1963, anthropologists to be both physiologically and sociolog- obviously crucial to an NCD prevention
in South Africa have demonstrated that ically plausible. Nevertheless, there are and control agenda in Africa. Maladap-
a simple notion of lifestyle is unlikely to tantalizing findings from research on the tationists are correct insofar as they per-
prove fruitful for the understanding of physiological and adrenocortical re- ceive that contemporary views on

Ethnicity & Disease, Volume 13, Spring 2003 S2-153


NCD-related risks are connected to the volves the network of ‘demographic sur-
past. In order to make this more than a veillance’ (DSS) sites around the conti- Without the full partnership
platitude, anthropologists can observe nent. These sites, with their continuous
changes in the uses and cultural percep- longitudinal monitoring of dynamic pop- of anthropologists, sociologists,
tions of salt, sugar, tobacco, fat, and al- ulation cohorts and their health, are gain- geographers, historians, social
cohol.95 They can also probe the very ing an increasingly important role and
meanings of modern consumption and voice in informing intervention policy demographers, and micro-
commodities,88 specifically in relation to and practice.97 In 1997, a global network
NCDs. ‘Traditional’ notions of body of such sites (the INDEPTH Network,
economists, efforts to confront
image and associations among fatness, was es- NCDs run the risk of
fertility, health, and wealth, for example, tablished. On top of these DSS platforms,
are virtual stereotypes in Africa. These a variety of long-term monitoring pro- repeating past mistakes.
need to be unpacked in specific contem- grams can be established to track popu-
porary settings with regard to ideas lation health, poverty conditions, and risk
about the life course, marriage, advertis- factors over time. One such effort, the matched with a commensurate commit-
ing, and mass media, and the effects of Tanzanian Adult Morbidity and Mortality ment to explore the complexities of
wealth upon individual behavior.96 A Project (, has community life. Local researchers and
richer understanding of this social/cul- already begun to explore the role of practitioners should be at the forefront
tural/biological nexus complements a NCDs in mortality transitions, and the of these efforts.
culture and political economy approach links of NCDs to impoverishment.98–100 It is hoped that the public health
and can clearly inform programs of pri- DSS sites, and the INDEPTH Network community concerned with the preven-
mary prevention. through which many of them assist each tion and control of NCDs in Africa will
other, have routinely focused on demog- be quick to embrace the involvement of
raphy and epidemiology, occasionally anthropologists and other social scien-
CAPACITY IS SCARCE, BUT employing anthropologists. Demo- tists. Without the full partnership of an-
OPPORTUNITIES EXIST TO graphic surveillance sites and IN-
thropologists, sociologists, geographers,
STRENGTHEN IT DEPTH are committed, however, to
historians, social demographers, and mi-
strengthening developing country ca-
cro-economists, efforts to confront
pacity, not only in the areas of demog-
The Global Forum for Health Re- NCDs run the risk of repeating past
raphy, epidemiology, and information
search is committed to addressing what mistakes. The ‘added value’ of strength-
technology/data systems, but also in
it has termed the ‘90/10’ imbalance in ening the local research and policy ca-
bio- and social statistics, anthropology, pacity will bolster the impact of the ma-
resources for research on health issues:
sociology, and economics. jor resource commitments advocated by
90% of global resources are spent on in-
The needs are too great to be met bodies such as the Global Forum for
vestigating problems affecting 10% of
by this channel alone, and those respon- Health Research and WHO.12
the world’s population. The successes
sible for supporting social research ca-
met by these efforts should not merely
pacity development focused on the lead-
be directed at issues, but also at the spe-
ing infectious diseases should consider ACKNOWLEDGMENTS
cific strategies for researching them
carefully the looming needs for these I am grateful to the members of the AMMP
through a range of disciplinary perspec-
perspectives in coming health transi- and ANSA Teams (members identified at
tives, including anthropology and other and
tions in Africa.
social sciences. Social sciences, and the, and to
strengthening of developing country ca- the community members who have partici-
pacity in social research, have long been pated in the AMMP and ANSA projects.
core components of WHO’s program of
CONCLUSIONS This publication is, in part, an output of the
Adult Morbidity and Mortality Project of
Tropical Disease Research. An acute the Tanzanian Ministry of Health, funded by
need exists to support African graduate While socio-cultural issues will clear- the UK Department for International De-
students and institutions desiring to be- ly affect NCD control, social science velopment (DFID), and implemented in
come involved in anthropological re- perspectives have been absent from both partnership with the University of Newcastle
search on NCDs in Africa. policy statements and action plans. In upon Tyne. The views expressed are not nec-
essarily those of DFID. Funding for the Ac-
A particularly important opportunity the new domain of NCD control in the tion on Non-Communicable Disease in Sub-
for capacity strengthening in social science ‘tropical disease’ context, the emphasis Saharan Africa (ANSA) project is from the
research on chronic diseases in Africa in- on community action should be European Union.

S2-154 Ethnicity & Disease, Volume 13, Spring 2003


REFERENCES Cross-Cultural Psychiatry of Affect and Disor- thropological perspectives. Soc Sci Med.
1. King H, Rewers M. Diabetes in adults is der. Berkeley, Calif: University of California 1978;12B:247–254.
now a Third World problem. The WHO Ad Press; 1985. 32. Gribble JN, Preston SH. Introduction. In:
Hoc Diabetes Reporting Group. Bull World 16. Riesman P. The person and the life cycle in Gribble JN, Preston SH, eds. The Epidemi-
Health Organ. 1991;69(6):643–648. African social life and thought. Afr Stud Rev. ological Transition. Policy and Planning Im-
2. Murray CJL, Lopez AD. Alternative visions 1986;29(2):71–138. plications for Developing Countries. Washing-
of the future: projecting mortality and dis- 17. Farmer P. Infections and Inequalities: The ton, DC: National Academy Press; 1993:
ability, 1990–2020. In: Murray CJL, Lopez Modern Plagues. Berkeley, Calif: University 1–8.
AD, eds. The Global Burden of Disease. Bos- of California Press; 1999. 33. Frankenberg R. Risk: anthropological and
ton, Mass: The Harvard School of Public 18. Schoepf BG, Schoepf C, Millen J. Theoret- epidemiological narratives of prevention. In:
Health on behalf of the World Health Or- ical therapies, remote remedies: SAPs and Lindenbaum S, Lock M, eds. Knowledge,
ganization and the World Bank; 1996:325– the political ecology of poverty and health Power, and Practice. The Anthropology of
395. in Africa. In: Kim JY, Millen JV, Irwin A, Medicine and Everyday Life. Berkeley, Calif:
3. Johnson TO. Diabetes in the Third World. Gershman J, eds. Dying for Growth. Global University of California Press; 1993:219–
World Health. 1991. 8–10. Inequality and the Health of the Poor. Mun- 244.
4. Bulatao RA, Stephens PW. Global estimates roe, Me: Common Courage Press; 2000:91– 34. Krieger N. Commentary: society, biology,
and projections of mortality by cause, 1970– 126. and the logic of social epidemiology. Int J
2015. Washington, DC: The World Bank, 19. Caldwell JC, Findley S, Caldwell P, et al, Epidemiol. 2001;30:44–46.
Population and Human Resources Depart- eds. What We Know About Health Transition: 35. Waldron I, Nowatarski M, Freimer M, Hen-
ment; 1992. The Cultural, Social, and Behavioral Deter- ry J, Post N, Witten C. Cross-cultural var-
5. Ministry of Health and AMMP Team. The minants of Health. Canberra: The Health iation in blood pressure: a quantitative anal-
Policy Implications of Adult Morbidity and Transition Center, The Australian National ysis of the relationships of blood pressure to
Mortality. End of Phase 1 Report. Dar es Sa- University; 1990. cultural characteristics, salt consumption,
laam: United Republic of Tanzania; August 20. Feierman S, Janzen JM, eds. The Social Basis and body weight. Soc Sci Med. 1982;16(4):
1997. of Health and Healing in Africa. Berkeley, 419–430.
6. Gwatkin DR, Guillot M. The Burden of Dis- Calif: University of California Press; 1992. 36. Dressler WW, Bindon JR. Social status, so-
ease Among the Global Poor. Current Situa- 21. Susser M. The tribulations of trials—inter- cial context, and arterial blood pressure. Am
tion, Future Trends, and Implications for vention in communities. Am J Public Health. J Physical Anthropol. 1997;102:55–66.
Strategy. Washington, DC: The World Bank; 1995;85(2):156–158. 37. Barnett T, Blaikie P. AIDS in Africa. Its Pres-
2000. 22. Daniel M, Green LW, Marion SA, et al. Ef- ent and Future Impact. New York, NY: The
7. Gwatkin DR, Guillot M, Heuveline P. The fectiveness of community-directed diabetes Guilford Press; 1992.
burden of disease among the global poor. prevention and control in a rural aboriginal 38. Sweat MD, Denison JA. Reducing HIV in-
Lancet. 1999;354:586–589. population in British Columbia, Canada. cidence in developing countries with struc-
8. Unwin N, Alberti G, Aspray T, et al. Eco- Soc Sci Med. 1999;48(6):815–832. tural and environmental interventions.
nomic globalization and its effect on health. 23. Feinleib M. New directions for community AIDS. 1995;9(suppl):S251–S257.
BMJ. 1998;316:1401–1402. intervention studies. Am J Public Health. 39. Krieger N. Theories for social epidemiology
9. Unwin N, Setel P, Rashid S, et al. Non-com- 1996;86(12):1696–1698. in the 21st century: an ecosocial perspective.
municable diseases in sub-Saharan Africa: 24. Farmer P. Culture, poverty, and the dynam- Int J Epidemiol. 2001;30:668–677.
where do they feature in the health research ics of HIV transmission in rural Haiti. In: 40. Woodward D, Drager N, Beaglehole R, Lip-
agenda? Bull World Health Organ. 2001; Brummelhuis HT, Herdt G, eds. Culture son D. Globalization and health: a frame-
79(10):947–953. and Sexual Risk. Anthropological Perspectives work for analysis and action. Bull World
10. Howson CP, Reddy KS, Ryan TJ, eds. Con- on AIDS. Luxembourg: Gordon and Breach; Health Organ. 2001;79(9):875–881.
trol of Cardiovascular Diseases in Developing 1995:3–28. 41. Setel PW. A Plague of Paradoxes: AIDS, Cul-
Countries. Research, Development, and Insti- 25. Inhorn MC, Brown PJ, eds. The Anthropol- ture, and Demography in Northern Tanzania.
tutional Strengthening. Washington, DC: ogy of Infectious Diseases: International Health Chicago, Ill: University of Chicago Press;
Board on International Health, Institute of Perspectives. Amsterdam: Gordon and 1999.
Medicine/National Academy Press; 1998. Breach; 1997. 42. Fouraste RF. [Social perception of arterial
11. World Health Organization, ed. Cardiovas- 26. Nyamongo I. The malaria cognate: folk clas- hypertension from a transcultural perspec-
cular research initiative in the developing sification of illness among the Abagusii of tive] (English abstract). Ann Med-Psychol.
countries. 2000. Available at: http:// Kenya. Afr Anthropol. 1997;IV(2):27–36. 1984;142(8):1087–1096. 27. Setel P. Overcoming structural obstacles 43. Packard RM, Epstein P. Epidemiologists, so-
12. World Health Organization. Regional Strat- among local implementors is key to AIDS cial scientists, and the structure of medical
egy for Non-Communicable Diseases (NCDs) prevention. World Health Forum. 1997; research on AIDS in Africa. Soc Sci Med.
in the Africa Region (2001–2010). Geneva: 18(2):215–217. 1991;33(7):771–794.
World Health Organization. 28. Blackburn H, Prineas R. Diet and hyperten- 44. Grmek MD. History of AIDS: Emergence and
13. Murray CJL, Lopez AD, eds. The Global sion: anthropology, epidemiology, and pub- Origin of a Modern Epidemic. Princeton, NJ:
Burden of Disease. Boston, Mass: The Har- lic health implications. Prog Biochem Phar- Princeton University Press; 1990.
vard School of Public Health on behalf of macol. 1983;19:31–79. 45. Pela AO, Platt J. AIDS in Africa: emerging
the World Health Organization and the 29. Dressler WW. Modernization, stress, and trends. Soc Sci Med. 1989;28(1):1–8.
World Bank; 1996. blood pressure: new directions in research. 46. Curtin P. Medical knowledge and urban
14. Janzen JM. Ngoma. Discourses of Healing in Hum Biol. 1999;71(4):583–605. planning in colonial tropical Africa. Am Hist
Central and Southern Africa. Berkeley, Calif: 30. Baer H, Singer M, Johnson J. Towards a Rev. 1985;90(3):594–613.
University of California Press; 1992. critical medical anthropology. Soc Sci Med. 47. Jochelson K. HIV and syphilis in the Re-
15. Kleinman A, Good BJ, eds. Culture and De- 1986;23(2):95–98. public of South Africa: the creation of an
pression: Studies in the Anthropology and 31. Comaroff J. Medicine and culture: some an- epidemic. Afr Urban Q. 1991;6(1–2):20–34.

Ethnicity & Disease, Volume 13, Spring 2003 S2-155


48. Packard RM. White Plague, Black Labor. Canadian women with diabetes—exploring guidelines (review). Annu Rev Public Health.
Berkeley, Calif: University of California factors that influence management. Soc Sci 1997;18:341–378.
Press; 1989. Med. 1995;41(2):181–196. 80. Nettelbladt P, Svensson C, Serin U, Ojehag-
49. Vaughan M. Curing Their Ills: Colonial Pow- 65. Dressler W, Balieiro M, dos Santos J. Cul- en A. The social network of patients with
er and African Illness. Palo Alto, Calif: Stan- ture, socioeconomic status, and physical and schizoaffective disorder as compared to pa-
ford University Press; 1991. mental health in Brazil. Med Anthropol Q. tients with diabetes and to healthy individ-
50. Callahan B, Bond V. The social, cultural, 1998;12(4):424–446. uals. Soc Sci Med. 1995;41(6):901–907.
and epidemiological history of STDs in 66. Dressler WW. Ethnomedical beliefs and pa- 81. Kleinman A. Patients and Healers in the Con-
Zambia. In: Setel P, Lewis M, Lyons M, eds. tient adherence to a treatment regimen: a St. text of Culture. Berkeley: University of Cal-
The History of Sexually Transmitted Diseases Lucian example. Hum Organ. 1980;39(1): ifornia Press; 1980.
and HIV/AIDS in Africa. Westport: Green- 88–91. 82. Blumhagen D. Hyper-tension: a folk illness
wood Press; 1999. 67. Dressler WW. Education, lifestyle, and ar- with a medical name. Cult Med Psychiatry.
51. Chirwa WC. Sexually transmitted diseases in terial blood pressure. J Psychosom Res. 1990; 1980;4(3):197–227.
colonial Malawi. In: Setel P, Lewis M, Lyons 34(5):515–523. 83. Blumhagen D. The meaning of hyper-ten-
M, ed. Histories of Sexually Transmitted Dis- 68. Dressler WW. The cultural construction of sion. In: Chrisman NJ, Maretzki P, eds.
eases and HIV/AIDS in Sub-Saharan Africa. social support in Brazil: associations with Clinically Applied Anthropology. Dordrecht:
Westport: Greenwood Press; 1999. health outcomes. Cult Med Psychiatry. 1997; D. Reidel; 1980:297–323.
52. Cooper F, ed. Struggle for the City: Migrant 21(3):303–335. 84. Weiss M. Explanatory Model Interview Cat-
Labor, Capital, and the State in Urban Africa. 69. Dressler WW, Grell GC, Viteri FE. Social alog (EMIC): framework for comparative
Beverly Hills, Calif: Sage; 1983. factors mediating social class differences in study of illness. Transcult Psychiatry. 1997;
53. Yonga GO. Development of risk factors for blood pressure in a Jamaican community. 34(2):235–263.
coronary artery disease in Africans. East Afr Soc Sci Med. 1992;35(10):1233–1244. 85. Tshabalala G, Gill GV. Cultural aspects of
Med J. 1998;75(9):493–494. 70. Garro L. Cultural knowledge about diabetes. diabetes in Africa. In: Gill G, Mbanya J-C,
54. Curtin PD. The slavery hypothesis for hy- In: Young TK, ed. Diabetes in the Canadian Alberti G, eds. Diabetes in Africa. Reach,
pertension among African Americans: the Native Population: Biocultural Perspectives. Cambridge: FSG Communications; 1997:
historical evidence. Am J Public Health. Toronto: Canadian Diabetes Association; 275–279.
1992;82(12):1681–1686. 1987. 86. Csordas T, ed. Embodiment and Experience.
55. Farmer P. AIDS and Accusation. Haiti and 71. Garro LC. Explaining high blood pressure: Cambridge, Mass: Cambridge University
the Geography of Blame. Berkeley, Calif: Uni- variation in knowledge about illness. Am Press; 1994.
versity of California Press; 1992. Ethnologist. 1988;15:91–119. 87. Lambek M, Strathern A, eds. Bodies and Per-
56. Greenhalgh S, ed. Situating Fertility. Anthro- 72. Garro LC. Individual or societal responsi- sons. Comparative Perspectives from Africa and
pology and Demographic Inquiry. Cambridge, bility: explanations of diabetes in an Anash- Melanesia. Cambridge, Mass: Cambridge
Mass: Cambridge University Press; 1995. inaabe (Ojibway) community. Soc Sci Med. University Press; 1998.
57. Schoepf BG. Political economy, sex, and cul- 1995;40:37–46. 88. Weiss B. The Making and Unmaking of the
tural logics: a view from Zaire. Afr Urban 73. Garro LC. Intracultural variation in causal Haya Lived World. Consumption, Commodi-
Q. 1991;6(1–2):94–106. accounts of diabetes: a comparison of three tization, and Everyday Practice. Durham,
58. Ahlberg BM. AIDS Prevention with women Canadian Anashinaabe (Ojibway) commu- NC: Duke University Press; 1996.
and youth in Nairobi and Njeri. Paper pre- nities. Cult Med Psychiatry. 1996;20(4):381– 89. Scotch NA. Sociocultural factors in the ep-
sented at: African Studies Association An- 420. idemiology of Zulu hypertension. Am J Pub-
nual Meeting; 1993; Boston, Massachusetts. 74. Hagey R. The phenomenon, the explana- lic Health. 1963;53(8):1205–1213.
59. Obbo C. The Language of AIDS in Rural tion, and the responses: metaphors sur- 90. Sapolsky RM. Endocrinology alfresco: psy-
and Urban Uganda. Afr Urban Q. 1991; rounding diabetes in urban Canadian Indi- choendocrine studies of wild baboons. Re-
6(1–2). ans. Soc Sci Med. 1984;18(3):265–272. cent Prog Horm Res. 1993;15:437–467.
60. Parker RG. Empowerment, community mo- 75. Hagey R. The Native Diabetes Program: 91. Shively CA, Laber-Laird K, Anton RF. Be-
bilization, and social change in the face of rhetorical process and praxis. Special issue: havior and physiology of social stress and de-
AIDS. AIDS. 1995;9(suppl):S27–S31. cross-cultural nursing: anthropological ap- pression in female cynomolgous monkeys.
61. Seeley J. Searching for Indicators of Vulnera- proaches to nursing research. Med Anthropol. Biol Psychiatry. 1997;41:871–882.
bility: A Study of Household Coping Strategies 1989;12(1[special issue]):7–33. 92. Wilkinson RG. Comment: income, inequal-
in Rural South West Uganda. Entebbe: 76. Heurtin-Roberts S. ‘High-Pertension’—the ity, and social cohesion. Am J Public Health.
MRC/ODA Research Program on AIDS in uses of chronic folk illness for personal ad- 1997;87(9):1504–1506.
Uganda; 1993. aptation. Soc Sci Med. 1993;37(3):285–294. 93. Greenfield SF, Borkan J, Yodfat Y. Health
62. Setel P, Mtweve S. KIWAKKUKI: a brief 77. Heurtin-Roberts S, Reisin E. Folk models of beliefs and hypertension: a case-control
history and analysis of a community-based hypertension among Black women: prob- study in a Moroccan Jewish community in
response to AIDS. In: Klepp K-I, Biswalo lems in illness management. In: Coreil J, Israel. Cult Med Psychiatry. 1987;11(1):79–
PM, Talle A, eds. Young People at Risk: Fight- Mull JD, eds. Anthropology and Primary 95.
ing AIDS in Northern Tanzania. Oslo: Scan- Health Care. Boulder: Westview; 1990:222– 94. Sokolovsky J, Sosic Z, Pavlekovic G. Self-
dinavian University Press; 1995:149–164. 250. help hypertensive groups and the elderly in
63. Varga CA. KwaZulu Adolescents Negotiating 78. Hunt LM, Valenzuela MA, Pugh JA. Porque Yugoslavia. J Cross Cult Gerontol. 1991;6(3):
Sex: Implications for Reproductive Health and me toco a mi? Mexican American diabetes 319–330.
HIV/AIDS. Durban, South Africa: Depart- patients’ causal stories and their relationship 95. Walker ARP. Nutrition-related diseases in
ment of Social Anthropology, University of to treatment behaviors. Soc Sci Med. 1998; southern Africa: with special reference to ur-
Natal; 1997. 46(8):959–969. ban African populations in transition. Nutr
64. Anderson JM, Wiggins S, Rajwani R, Hol- 79. Krieger N, Williams DR, Moss NE. Mea- Res. 1995;15(7):1053–1094.
brook A, Blue C, Ng M. Living with a suring social class in US public health re- 96. Treloar C, Porteous J, Hassan F, et al. The
chronic illness: Chinese-Canadian and Euro- search—concepts, methodologies, and cross cultural context of obesity: an IN-

S2-156 Ethnicity & Disease, Volume 13, Spring 2003


CLEN multi center collaborative study.

Health Place. 1999;5:279–286.
97. Tollman SM, Zwi AB. Health system re-
form and the role of field sites based upon
demographic and health surveillance. Bull
World Health Organ. 2000;78(1):125–
98. Bovet P, Ross AG, Gervasoni J-P, et al. Dis-
tribution of blood pressure, body mass in-
dex, smoking habits, and associations with
socio-economic status in Dar es Salaam,
Tanzania, and associations with socioeco-
nomic status. Int J Epidemiol. 2002;31:240–
99. Setel P, Hemed Y, Whiting D, et al. The
worst of two worlds. Adult mortality in Tan-
zania. Insights Health. March 2001;1:3–4.
100. Walker RW, McLarty DG, Kitange HM, et
al. Stroke mortality in urban and rural Tan-
zania. Lancet. 2000;355(9216):1684–

Ethnicity & Disease, Volume 13, Spring 2003 S2-157