Saturday, 28 March 2009

Diabetes as a Social Illness

Diabetes as a Social Illness.


People who talk negatively about health care providers are those who are not sick.    Dr James Kerr


I am a Doctor, my father was a Doctor, my brother is a doctor, my sister in law is a doctor, so I don’t want you to misrepresent what I say as prejudice towards Doctors.


Reductionism and Construction

These are not the terms health care providers are familiar with, but any undergraduate student in Anthropology can explain it to you.


Bringing a large amount of fact, reducing them to suit your hypothesis.

Focusing mainly on one small part of the body or viewing physiological or organic data as somehow more real than the social, cultural, psychological or spiritual aspects of health and illness


An example of that would be: Indians do not seem to be happy, so give them a questionnaire and if they answer yes to three out of five questions, they are depressed.

Indians and Depression, I wish to come back to it later. Have you noticed all of a sudden , since the easy availability of Prozac, Zoloft and Paxil, more and more Indians are depressed? Which came first, the egg or the chicken. I will explain later.


Creating a Hypothesis, backed by scientific data but out of context and believing in it , preaching it.


In Atlanta, a recent study showed, 32% of the inhabitants had Hight BP

In San Antonio, GDM is seen 1/5 young women.

In Gila River Reservation, one in every two person has Type 2 Diabetes


So, if I am giving a lecture in Australia


It would be wrong for me to say



1/3 have HBP

1/5 pregnant women have GDM

1/2 adults are Diabetic


Of course, I have the epidemiological and scientific data to prove it, but I forgot to mention an important thing.

The Context in which the research was done..

Majority of the inhabitants of Atlanta are BLACK

San Antonio is predominantly MEXICAN

Gila River is 100% Indian


In the name of political correctedness, the scientists, whether they are biomedical or social scientists  ( endocrinologist would be a biomedical scientist, an anthropologist would be a social scientist ) began to say that there are no difference in people, some even going as far as to say: Race as such does not exist…


I maintain

American Indians including Dene in Alaska to Yamana in Tierra del Fuego

Are different from their European counterparts

Not only

In the way they think

But equally importantly

The way the body works..


I am not talking about acculturation. I am  JEW but that does not mean that I cannot learn to use powerpoint presentation!  My westernization ( growing up in Australia, educated in Australia, UK and USA ) does not affect

My cultural identity

My sense of a person and belonging


Cultural and Spiritual Identity Crisis is the deepest social crisis affecting Western countries and I believe that the indigenous people whom they conquered 500 years and less ago will offer them a way out. But that is another story..


Physical, by that we mean Metabolic differences

When it comes to Chronic Diseases, we must believe in the research done by ourselves on Indians, rather than trying to incorporate the research done elsewhere and adapting it for the Indian.


This applies to



High Blood Pressure

Kidney Disease

Coronary Disease


Al the above have one thing in common

Not only they are chronic

But they are all preventable.


And in each one of the above diseases, the measurements, and what they reflect in the metabolism of the Indian is debatable…


Following are some examples and I can explain them well from a physiological and cultural view points. So a cultural explanation may coexist..


Blood Sugar and bringing it down by exercise…

Cultural Explanation


High Blood Pressure

Alcohol and its effect

What is normal blood pressure?



If low HDL is predictive of Heart Disease, how can we explain that close to 80 % of the indigenous people have low HDL?


High Triglyceride



Thin Membrane Disease

Inability to increase glomerular filtration rate is one of the earliest manifestations of impending kidney disease.



Increased alkaline phosphatase

Low or nonexistent CPK


Ability to manouevre BS, BP with diet and activity


Family history of Diabetes?

Genetic Susceptibitlity?


Absence of Type I DM?


At one time I decided to write down the difference in the ways of thinking of American Indians and Americans… it was pages and pages long.. may put here one day..


By the way, most Indians (the native people of the Americas) refer themselves by their tribal identity, rather than the so called politically correct Native Americans..


Will continue this subject later on..





The ancient capital of Bagan in Birmania, lies on the banks of river Irrawady. It is one of the patrimonio de la humanidad with hundreds of monuments and archeological sites and one of the more visited tourist areas in Birmania.

In 1999, the Government decided to move the entire population of Bagan to a new site away from the tourist areas and gave them just fifteen days to move: the old houses were erased, but there were no new houses, but the people had to shift, build houses and begin adjusting to their new life.

Within months, the old people began to die.

The doctors and the statisticians and the salud publica said: they died of pneumonia because of changes in the air and infections.

Do you believe that?

Can you think of the real reason why they died?


Each society has symbols which are visible and symbols which are invisible and some shared and some not shared.


Anthropology teaches us to unravel (decifrar) the symbols that surrounds a particular


Some people within the society: Blacks and Whites; Jews and Christians


Philosophically, we can ask

Is the truth there to be discovered and then social factors added or those leaning towards Marx might say

The discovered truth is a social product.


When you look at something.. let us say an object, a scenery

If you wear dark glasses, they would appear dark

If you wear green glasses they would appear green


It is the lens that makes the difference, not the object

The object remains the same.


The way of looking and explaining it

Is to know the lens through which we look at things

Whether it is life or suffering or relationships


And what is this lens




And I would like you to think about and write down for me

What you think society is?

What do you think culture is?


I can already tell you there is no correct answer since there is no single answer…



All of us have a story


It is the absence of a story, a lived in and experienced story..Antoine Artaud, from his asylum said, as quoted by Michel Foucault,

Madness is an absence of an ouvre


Suicide is an absence of an ouvre


The reason why people become fat when they migrate to United States is because their stories are being interrupted…


When you put an Australian aboriginal in Jail, he dies or hangs himself

Let me recite what a Bushman said, away from his habitat

I am waiting for the moon to change

So that I can listen to the stories of my people

I am here and I have no story

I want to listen, waiting for a story come to my way

And to come to my ear

I will sit, turn my ears backwards because I know there is a story in the wind..


All of us have a story

Not what we are

But who we are


I am Sudah Yehuda Kovesh Shaheb and a Jew

That is who I am

I am Yehuda, endocrinologist and medical anthropologist

That is what I am

Photo shows my brother Elliott and I praying for our brother Ricardo in front of the Nats at Old Bagan.



Learn to be true to yourselves, to know who you are, which is a struggle as Dalai Lama would say.


If I give you this visiting card of mine, which has a portrait of Ernesto Che Guevara.

You would look at this with the lens you have created for yourself

And come to an entirely different conclusion

This guy likes Che

Which has got different sentiments in different countries

In usa  they would say  this man is a communist

In cuba they would say this man sympathetic to Cuban revolution

But that would not reflect who I am


The point of this

Symbolism has to be transacted,

one must learn to transact symbols in the societies where we live, whether as natives or immigrants to be emotionally stable.


Hermaneutics is a term used to describe the views concerned with the problems of understanding and interpretation. Wilhelm Ditte a 19th century German historian and philosopher. He was aware (comprendido) that the texts were merely one form of what he called objectification of life ( objectivization ). To understand cultural phenomena, is to grasp (tomar) them as objectified expressions of life, and to experience the creative act, to really read the experience of others


(in a way de-objectification…very similar to what Jacques derrida was to say much later.. deconstruction )


Studying Medical Anthropology, you will learn no statistics, you will have no more knowledge about any one subject( material) but you will learn a new way of thinking.


This is what I would like you to think about

To look at things, whether they are constructed or true

And can it be deconstructed?


A constructed life, is false, is like a boat without an anchor, a man without a culture, following the wind as it comes and without direction


Studying Medical Anthropology, you would realize that it is not Medicine you are studying, even if you are doctors or people working in the health professions ,

but it is about LIFE

It deals with Birth


Family and relationships

And Death.


Almost nobody in my family is related to me by blood, does it mean that I have no family?


Among the Indians, all your mothers sisters are your mothers. The blood mother never disciplines the child, the others do.


LIFE is also about suffering: emotional, physical and psychological, spiritual.


Western medicine, trumpeting its technical superiority has hijacked the management of suffering.. and we shall study the history of this hijacking and its continued dominance.


In short,( en sintesis ) Medical Anthropology  is a Metaphor for LIFE ( de la vida )

And that is the title of this course


Medicine as  Metaphor for LIFE..


Medicine has become the major metaphor in our societies.. regardless of whether it is a rich European country or poor african country




We say Economy is Sick, violence is cancer of the society, the institutions are ailing…civilizations are being described as wounded…


Una poema desconocida de Pablo Neruda

Patria Prisionera


Patria de mi ternura y mi Dolores..

Hoy sangran tus banderas tricolors..


But once upon a time, the metaphor for the society was RELIGION

Sinful life they used to say, now we say unhealthy lifestyle.


It is so because, Health is at the core(center) of the human experience: as we mentioned before, birth, pregnancy, marriage and suffering.


The British Anthropologist Lewis said:

Nothing distinguishes one community more sharply from another than its beliefs concerning the meanings of life, the position of the people in the universe, which is called the world view and the ultimate significance of affliction and suffering.


I have already mentioned to you that the objects appear differently to different persons through the lens of culture; but there is only one truth. To each person, the truth exists but the problem is when someone else tells you what is the truth.


Let us look at painting by Edvard Munch the melancholic Norwegian painter.. Scream (el grito) is his best known painting..

Each one of us would perceive it differently.. red is good luck for the Chinese, for the ndembu in zambia, red denotes menstruation and thus a taboo..

If we use Hermaneutics.. way of interpreting.. transaction of societal symbols.. we would realize that the painting is an objectification of Norwegian life…

He was trying to portray to us the narrow mindedness, the hypocrisy, the complaisance of the Norwegian society at the end of 19th century… If you read the Norwegian literature of that time..Knut Hansen in his book HUNGER or Ibsen the playwright who was Hansen’s contemporary…Hedda Gabler is one of his plays…all portray the hypocrisy of that society. Munch painted what Hansen wrote and what Ibsen’s drama represented…


The study of Medical Anthropology would be incomplete without studying DESCARTES… Ergo, cogito sum…I think, therefore I am…which had been translated into our times as  I doctor, therefore I am…


From him comes Cartesian Dualism…

Palpable mind and the intangible body

Body and soul

One left to the church

And other to the intellectuals in society


Think of it as, wresting the control of the society away from the all powerful church..

Remember, at this time, hospitals, doctors as an organized profession or specialization by organs did not exist and they were at the beck and call( servicio y llamado ) of the bourgeoisie, a pawn(peon) in the hands of the powerful. In our studies of medical anthropology, you will understand how the medical profession has always remained the pawn in the hands of the powerful forces in the society.. the guiding principles have never been the health or welfare of the society as a whole..


What is the general opinion of health care and health care professionals around the world at the moment, especially about those who are trained in the western medical model?


The physician and the specialist, whatever his field, should study the entire patient and his environment, and should view disease with the eye of the naturalist. That is the message of Hippocrates, as fresh today as it was 2400 years ago.

Eventhough Hippocrates rejected philosophical approach to Medical care and took a more scientific approach, he refrained from diagnosing conditions and prescribing specific medicines for each illness.


Holger Kalweit

There are three things our culture has forgotten: basic health, healing and holiness. All three words have the same linguistic root and the concepts have the same goal: sanity, integrity, completeness, salvation, happiness, liberation , magic


Shamanic therapy means the healing of an entire life rather than just healing failing functions and disruptive pains. For shamans, healing involves philosophy, a view of life.


An initiation into shamanic healing means a devaluation of all values, an overturning of the profane world, a peeling away of inveterate handed down notions of the world, liberation from everything preconceived. For that reason shamanism is closely connected with suffering. One must suffer the disintegration of ones own system of thought in order to perceive a new world in the higher space


He had the soul of a child  and the mind of a philosopher


To be a healer


Foucault  : The Birth of the Clinic

Medicine of the past two centuries or so has been conducted increasingly

“without regard to persons”..Max Weber

hence( por la tanto ) the frequent critiques of

hospital medicine


doctor-centred medicine

medical model

sometimes an underlying principle is invoked to explain this state of affairs:

medicalization  ilich

professionalization  parry and parry

scientifization  pelling


a kind of anti-medical model perhaps is pleaded for, humanist, caring, individualizing, preventative, progressive, person centred, phenomenological, ideographic etc..


it is not a rejection of medicine altogether

a part of it is sentimentalism much like nostalgia with regard to medicine

anti medicine ethos is not a philosophy but a kind of schema, a way of thinking that is drawn upon selectively by different sets of people in different contexts


I wish to emphasize the fact that by studying health care systems or health seeking behaviour, we are not attempting to replace it, or eradicate it, but humanize it more, to complement it. And to contextualize it.. when do we need the doctor, when do need  the sangoma, when do we need the santo, palero etc.


I hope you are beginning to understand what I am driving at…you need to have a basic understanding of the philosophy of the culture ( which whether you like it or not in cuba is predominantly western ) to understand the health care system whether as an observer, participant or a patient…


Otherwise you would accept things as they are…


In England, social anthropology is the dominant approach and emphasizes the social dimensions of human life. Man is a social animal, organized into groups that regulate and perpetuate themselves, and it is man’s experience as a member of society that shapes his view of the world.

In the USA, cultural anthropology focuses more on systems of symbols, ideas and meanings that comprise a culture, of which social organization is just an expression.

Both are complementary perspectives.. on how human beings organize themselves and ways that they view the world they inhabit.

In other words, one emphasizes the culture and the other emphasizes the society.


When studying a group of people, it is necessary to study the features of both their society and their culture.



Study of human languages, culture and society as structures. The elemental components are related to each other

So to analyze cooking ( or economics or kinship or illness)

Examine its components in the relationships of





Ferdinad Sassure

Roman Jakobsen

Claude Levi-Strauss

Lacan: the conscious is structured here as a language

Luis Althusser

Roland Barthes



A philosophy of consciousness

Neither intellectual nor science can grasp the fundamental nature of consciousness

To do this, philosophy has to deal with phenomenon-

Appearance and our awareness of the appearance.

This awareness cannot be understood through rational proofs and scientific data

What is needed is INTUITION

And a direct approach to the inner structures of the consciousness itself.


Edmund Husserl

Martin Heidegger

Maurice Merleu-Ponty  ( who with Jean Paul Satre wrote Les temps Modernes )


If I say to you


And you begin to explain to me that

Blue is an English word for a wavelength in the visible light spectrum…

You must then read Husserl’s work to see how he viewed the relatioship between science and philosophy. ( there was a scene in Swedish movie, I think it was called the Inspector where the child asks the mother: is there a man in the moon? And she gives him a scientific explanation and the child was so disappointed. He wanted to know about the man in the moon..perhaps a magical explanation rather than a rational one )


If you said, I don’t know. You said the word BLUE

Good.. there are twenty meanings for the word BLUE in English.. until I say a complete sentence,

BLUE is just another word





Jean Paul Sartre coined the term Existentialism to describe his own philosophies

The Underlying concepts of existentialism are simple:

Mankind has free will

Life is a series of choices, creating stress

Few decisions are without any negative consequences

Somethings are irrational or absurd, without explanation

If one makes a decision, he or she must follow through.


Fyodor Dostoevsky

Seren Kierkegaard

Fredrich Nietzche

George Hegel

Franz Kafka

Simone de Beauvoir

Albert Camus

Karl Jaspers


Jean Wahl

Gabriel Marcel


Influential philosophers and writers, with existential concepts relflected in their works include

Nicolas Alexandrovich Berdyaev  Russian Neo romanticist

Leo Isakovich Shestov Schwarzman  Russian Irrationalist

Jose Ortega y Gasset

Miguel de Unamuno


Algerian born French Jewish Philosopher Jacques Derrida ( 1930-2005) is one of the two most famous investigators of what is called POST MODERNISM in contemporary philosophy ( the other of course is Foucault )


His way of thinking is considered DECONSTRUCTION.


Plato’s thoughts had dominated the western thought for millennia.

In a memorable passage in The Twilight of Idols, (ocaso de los idolos )

Nietzche describes:

How the true world became a fable

Here he sketches an account of the gradual dissolution of the (other-wordly way of thinking )common to Plato, Christianity, and to Kant,

The way of thinking which contrasts the

True world of reality with the

World of appearance created by senses or matter or Sin

Or the structure of human understanding


The aboriginal peoples do not have a concept of Sin

If you think something is bad, don’t do it.

(Yakama Indians do not have a word for Sorry)

If you think that what you say will hurt the other, don’t say it…


The characteristic  expressions of this other worldliness, this attempt to escape from time and history into eternity, are what deconstructionists often call

The traditional binary oppositions

True –false



Objective-subjective and so on


( even the UN resolution on world Health says:  Health is the absence of Disease )

American Indians may have been the first ever deconstructionists when they said: The white man speaks with forked tongue.


In Laos, reading the official newspaper you realize that the News they print is not what has happened but what will happen in the future…



Derrida calls


Derrida repeats Heidegger’s claim that this metaphysics is utterly pervasive in Western Culture.

Both see the influence of the traditional binary oppositions as infecting all areas of life and thought, including literature and criticism of literature.


( Carl Gustav Jung mentions this: Darkness is not an absence of Light; Like Indians, Darkness and Light coexist. A better example of Indian way of thinking, in contrast to the Christian way of thinking is: Goodness is an absence of Evil, no, Goodness and Evil coexist, you choose the good path )

So Derrida entirely agrees with Heidegger that the task of the thinker is to twist free of these oppositions, and of the forms of intellectual and cultural life which they structure.

However, Derrida does not think that Heidegger succeeded in twisting free.


(In order to distance himself from Heidegger, Derrida proceeds to invent bits of philosophical terminology ( trace, difference, supplement and archi-ectriture and many others )..


Derrida expresses his affectionate admiration for the proliferating, the elusive, the allusive, the


He sees these features as exemplified in writing better than in speech-thus reversing Plato’s ( and Heidegger’s) preference for the spoken over the written word.


(spoken word is pre modern and written word is post modern , if you want to say )(oral history for example of the various tribes)

Thus Derrida positioned himself as the first post-metaphysical thinker, the prophet of an age in which reality-appearance distinction has ENTIRELY lost its hegemony over our thought.


Heidegger’s own sentimental pastoralism and nationalismotraits which led him to Nazism


Derrida turned  from Heidegger’s sentimental question

How can we find traces of the remembrance of Being in texts of the history of Philosophy?

To the quasi political questions

How can we subvert the intentions of texts which invoke metaphysical oppositions?

How can we expose them as metaphysical?

He turned from Heideggers preoccupation with the philosophical canon to the development of a technique which could be applied to any text, past or contemporary, literary or philosophical.

This was the technique which has come to be called DECONSTRUCTION


Derrida was made famous ( in English speaking countries ) not by his fellow philosophers, but by literary critics ( who were looking for new ways of reading texts rather than new understanding of intellectual history )

A deconstrutionist school of thinking came about ( with derrida as its leading figure)

As used by members of this school, the term DECONSTRUCTION refers in the first instance to the way in which

ACCIDENTAL features of a text can be seen as betraying, subverting, its purportedly ESSENTIAL MESSAGE.


Construction of medical knowledge ( Foucault has written about this )


Intuition in diagnosis is being replaced by reliance on technology and what backs up the technology, what is written about the technology? The communication to make sure that knowledge is transmitted is couched in a language ( serving some other master rather than the health of the patient: profit of the technology, drug companies etc )

How can we find words which directly reflect the world,  from non language?

The struggle has been going on since the time of Greeks, but it is doomed to failure because as

Saussure says: language is nothing but differences.

Contextual ( a concept very important in anthropology )

That is, words have meaning only because of contrast-effects with other words.

BLUE means what it does

Only by contrast with RED<>


This is an introduction to Medicine as a Metaphor for Society for those of us whether Cubans living in Cuba or an Australian living in Cuba.


We are profoundly influenced by the Siglo las Luces, Descartes and the scientific discoveries of 18th and 19th centuries and the philosophies of the western world: in my own case by

Giles De Leuze   person as a desire

Michel Foucault  Power, control and Punishment

Jacques Derrida  De Construction



The special significance of Foucault’s investigations of the body and the construction of medical knowledge springs from his keen recognition of the biomedical roots of modern ways of thinking in the social sciences.


Merton 1957 USA Social Theory and Social Structure

Assumed that while social factors might either impede or facilitate the emergence of discovery, they could not affect the content of knowledge. In effect, the sociologist was restricted to the contextual events surrounding the discovery and use of knowledge but could have no interest in the knowledge itself.

Thomas Kuhn The structure of Scientific Revolution in 1962

Showed also that the internal cognitive structure of science could be an object of social enquiry


Advent of hospital medicine in late eighteenth century

Physical examination, autopsy, statistics

As the basis of the new form of medicine

Hospital Medicine

It was apparent that the advent of the hospital provided the opportunity for the traditional dominance of the upper class patient over the doctor to be reversed in that the new public hospitals recruited patients from lowly backgrounds and invited relatively high status physicians to treat them.

Client control to medical dominance.


Still employing Ackerknecht’s periodization  of a pre hospital bedside medicine followed by hospital medicine, Jewson examined the effect of the hospital on medical knowledge.

Hospital provided a locus for a new relationship between doctor and the patient, it was this relationship that was instrumental in establishing the new biomedical model of medicine.

During Bedside Medicine, the patient was in a position to dictate ( and define ) the nature of illness; hence the existence of a symptom based medicine. After the advent of the hospital the doctor’s dominant role ensured the emergence of a medicine based on pathological lesions which were inaccessible to the patient without medical interpretation.

Thus this correlation between doctor-patient relationship and the form of medical knowledge was not only important in the genesis of the latter, it also functioned to maintain that particular relationship. A hierarchical relationship from which we suffer


The major impact of Jewson’s work was to undermine the assumption that medical knowledge was discovered. The notion of discovery, in which hidden truths wait to be revealed, allowed social factors to affect only when that truth was revealed, since the truth itself pre existed the act of discovery. The alternate model was to challenge the notion that truth awaited revelation and to argue that “discovered” truth was as much a social product as the search which laid it bare. ( in modern medicine, the best example of this is the “discovery” that cholesterol is harmful to the heart or half the population is “discovered” to suffer from some form of depression or “attention deficit disorders” in children)

Thus the emergence of pathological medicine, in which disease was reduced to skin encapsulated lesion, was not a discovery but a creation.


The eighteenth century medicine based on patient dominance, which accordingly recognized the primacy of a patient-defined agenda, was usurped by a medicine which treated patients as objects and ignored their words in search for the underlying pathological basis of illness. In consequence the autonomous identity of the patient was alienated by the new mechanistic forms of clinical practice



More fruitful ways to understand the origins and nature of clinical practice.

According to Foucault changes in medicine were simply one facet of a wider cognitive revolution: certainly diseases were “fabricated” by medicine, but so were the bodies that contained the diseases; this production of bodies was common to a range of techniques deployed through schools, prisons, workshops, barracks and hospitals. Fundamental to these new techniques of the body was a reconfiguration in the “power mechanisms” operating in society. The old regime was characterized by sovereign power, in which the body of the king symbolized the concentration of a centralized power: procedures were carried out ion the bodies of the king’s subjects

Foucault argued that this system of sovereign power was joined by a more pervasive system of disciplinary power in which the supreme body did not belong to the king but to “everybody”. Sovereign power has not disappeared but has continued, at least in symbolic form

“we still have not cut off the head of the king”

disciplinary power has grown ever more extensive and pervasive


The task has been to identify new knowledges of the body and their accompanying practices which sought to transform ( fabricate) a new object. For example, there are the various regimes of mental hygiene, which identified the neuroses as endemic in the population ( unlike the old insanity which was restricted to the unfortunate few ) and then used this knowledge to justify further surveillance of the population’s mental functioning. Eg teenage pregnancy.. analytic techniques which transformed it from a moral framework of condemnation to a surveillance machinery of betterment… teenage pregnancies are common in USA and England but not in Germany.


(social objects are constructed through perception. Of course, at one level, it appears rather trivial observation as it is only perception that the world is apprehended, but the core tenet of constructivism is that these perceptions are patterned by and through social forms)


( Humoral medicine.. humors..could the skilled physicians of the past identify humours which are beyond our perception or was it a delusion, an error? From the perspective of the present, with great arrogance, it is all too easy to believe that only the most recent reveals the truth and the past was marked with error, charlatanism and self deception.

Then why are people going back to Budhism, Yoga, acupuncture, Meditation, herbalism, homeopathy…is the knowledge about the body being constructed socially again or challenged or re constructed?

Or is the study of the constructed body imply the history of the body?


In the USA, the most expensive country to be sick, people spend more money on alternative medicine than the hospital and doctor based medicine.

Sudah Yehuda Kovesh Shaheb


Fellow of Royal Anthropological Institute, London

Consultant Endocrinologist

Consultant Medical Anthropologist

Various Indian Tribes

Visiting Professor of Anthropology

University of Habana, Cuba

Clinical Assistant Professor, Creighton University School of Medicine.   Associate Lecturer, Brunel Univesity, London