“Juana,” a Mexican immigrant who lives in Birmingham, Alabama, is a native of a small ranching village in Jalisco. Fifteen years ago, her husband lost his job in Mexico. They had no money saved, and she was scared for the safety of her children because of drug-related crime in their community there. Her husband convinced her that they needed to move to the U.S. where he could find work, they could get their kids in good schools, and they could have better lives. He went first, and, a little while later, Juana paid a “coyote” to take her across the border. After a month-long, treacherous journey, during which she was arrested and sent back, attacked by wild animals, left behind in the desert without food or water, and was constantly scared, she finally made it across the border and eventually to Alabama where her husband was living. He found steady work, and they sent for their three kids, who are now participants in the Deferred Action for Childhood Arrivals program. Juana and her family have achieved all the things they set out to achieve in moving to the U.S. Yet her health has suffered considerably, both physically and mentally. Unfortunately, this is not an uncommon experience for people like Juana.
The typical framework used to study what happens to individuals who developed in one sociocultural context when they attempt to live in another is called “acculturation.” In my work with Mexican immigrant women in Alabama, I’m trying to figure out what the acculturative process looks like and why typical measures of acculturation are associated with a dramatic decline in health outcomes, particularly diabetes and depressive symptoms. To understand how cultural meaning systems change and the effects of such meaning on human lives, we need to have a clear concept of what culture is, how it works, and ways to measure it. A cognitive definition of culture is a good place to start because it moves culture out of the realm of abstraction and allows for it to be measured in concrete terms. As Dressler point out in a previous post, culture is the information needed to think and behave appropriately in certain situations and to interpret the behavior of others correctly. This knowledge is encoded in overarching cultural models, which we draw on to structure our understanding of how we ought to live. Once we have an idea of what a cultural model looks like in a certain context, we can measure individuals against it and see how well they stack up. That stacking up is termed “cultural consonance“—the ability to live up to the shared cultural expectations of the group—and it affects health.
So, what’s going on with women like Juana? We know they tend to be in better health upon arrival than their U.S.-born counterparts, despite tremendous suffering before and during immigration. However, as they carry out their lives in the U.S.—even as their standard of living improves and they gain access to better health care—their health often gets worse. Researchers haven’t been able to explain the underlying cultural mechanism responsible for this. I’m interested in using cultural consonance as an intervening variable between measures of acculturation and health outcomes to determine if the pathway by which acculturation leads to declining health is, at least in part, in its effect on the ability to achieve a culturally valued lifestyle.
I focus on four cultural domains—lifestyle, family life, Mexican immigrant identity, and life goals. Using a technique called free listing, I asked my informants to list as many items as they could in response to these four questions:
What kinds of things are important or necessary to have a good life?
How would you describe a loving family?
What are the qualities or characteristics of Mexican immigrant women?
What are your goals in life? This gives me a glimpse into how cultural realities are changing in a new context
The next step is to understand what kinds of things go together and why as well as which items are most highly valued and sought after. This is analyzed using cultural consensus analysis, which measures the extent to which cultural knowledge is shared among informants and provides the best representation of how the collective thinks about a particular domain.
In general, people act in ways that correspond to cultural influences and expectations. I believe that, as Mexican immigrant women carry out their lives in the U.S., they internalize a new cultural model for how one ought to live, and, as they do this, their positions in the cultural landscape change. The further away they find themselves from living a collectively valued lifestyle in their new U.S. cultural context, the greater risk their risk for declining health. For Juana, adapting to a new culture has been difficult. For example, speaking Spanish in the home and celebrating Mexican traditions is very important to her, but she struggles to get her children to do this, which is a source of family discord. Another thing is that she is scared to drive, so she can’t get around easily and has lost her sense of independence.
Reasons for cultural dissonance among immigrants may range from economic constraints, structural or interpersonal violence and abuse, or lack of interest in engaging with a new culture. I hope to improve understanding what role culture plays in immigrant health outcomes as well as what social and institutional factors may limit the achievement of a culturally valued lifestyle. Such limitations may simply produce new stress that contributes to poor health outcomes.
The phrase “a working definition” is something that is encountered frequently in the literature in the social sciences. As an adjective, “working” is usually used in the following sense that appears in Webster’s: something that is “adequate to permit work to be done.” Note the use of the word “adequate.” There is the connotation of a definition that is rough-and-ready, somewhat unrefined, but that will suffice for the moment. At the risk of being accused of making one of those little academic ironic jokes—and if I am so accused, I will confess immediately that I am guilty—I intend to use the phrase in a different way. What I mean to talk about is a definition of culture that works, that can be used as both a theoretical and a methodological tool in understanding—in short, a definition that really does something.
The reason that I am approaching this essay in this way is because of the occasion: the considerable honor of having been chosen for this year’s Burnum Award.* This award is made on the basis of an overall research career, and hence this lecture is my opportunity to engage in a kind of retrospective examination of that research career. It has been 30 years since I decided, as a junior at Grinnell College, to pursue anthropology as a profession—which sounds like a long time even to me, although it feels like a short time. There are many ways I could think about and talk about those 30 years. My own view of what I’ve been doing really has most to do with the core idea of the field of anthropology: namely, the concept of culture and how to make it work in the research process.
My area of research is the intersection of culture, health and healing. What anthropologists like me do is to go around the world examining how culture shapes both the risk of disease and what it is that people do to recover from disease or illness. Obviously, we are talking about a wide range of questions encompassed by this area. In my own research, I have concentrated on the initial stages, namely, falling ill. How does culture shape that risk of disease?
The first question here is: what evidence is there that culture shapes disease at all? The short answer to that is: the epidemiologic transition.
In Figure 1, we see several countries in the Western hemisphere, comparing mortality rates from all causes of child mortality and from coronary heart disease (CHD). All-cause child mortality can be used as a proxy for various kinds of infectious and parasitic diseases (often summarized in official statistics under the heading diarrheal diseases) that tend to wreak greatest havoc among the most vulnerable in a population. CHD is foremost among the variety of chronic diseases. In some countries, child mortality equals or exceeds chronic disease mortality, while in others child mortality declines dramatically and chronic disease mortality increases equally dramatically.
What accounts for this difference? Some obvious answers come into play. Basic infrastructure like clean water and effective sewage systems, plus immunization programs, make a big difference. Also, in the process of economic development people have tended to become more sedentary with the related risk of obesity, which can contribute to many chronic diseases. The quality of our diets has changed, with much less fiber, more fat and more of other nutrients like sodium. Does the combination of these factors not account for these differences?
Well, actually, no. Certainly all of these factors play a role in the process, but even after their combined effects are removed, there are still societal differences in disease rates that are left unexplained.
Figure 2 shows another brief example of how sociocultural factors shape disease. The increase of blood pressure with age, as shown here for the West Tuscaloosa community, is taken to be “natural.” But if we compare this age distribution to the Zoró Indians of the Amazon basin, we see that the rise is not necessarily “natural,” but in some sense relative to cultural context. Again, a typical approach to unraveling these differences would be to look at issues such as diet and physical activity, and perhaps genetic predisposition.
But I want to take a moment to reflect on the logic that is being employed here. This logic unwittingly employs what has been called the “onion metaphor” of human beings. That is, we can forget about the Zoró’s mixed horticultural and fishing subsistence economy; we can forget about their system for tracing kinship relationships that is more complex than our own; we can forget the way in which they form household and family relationships; we can forget about their origin myths and conceptions of the supernatural. We can, in other words, strip away everything that makes them culturally different, in order to look at their physical activity or their diet to explain their blood pressure. Like stripping away the successive layers of an onion, this metaphor goes, we can strip away cultural difference to get at what is psychologically universal about people; we can strip away belief, value and personality and just look at behavior; we can strip away behavior and look at nutrient transport in the circulatory system; we can strip away physiologic process to look at base-pair coding. We can, ultimately, find our way down to what is fundamentally causative.
Or, can we? Could it be that the onion metaphor is just that, a metaphor that says more about how we look at the world and less about how the world really works? Could it be that we are as thinking, feeling, interacting, and, yes, biological entities, so suspended in a matrix of culture that to think we can strip it away as mere surface appearance so violates the phenomenon that we misunderstand it?
To even entertain this thought demands a way of conceptualizing culture that is subtle and nuanced, and at the same time that is hard-nosed and pragmatic. The concept of culture has to do some work in the research process.
So, what do we mean by culture? A fairly typical view, both in common language and in the way anthropologists have approached their work, sees culture as a shared body of custom, reproduced through time, that makes societies distinctive. Over a century ago, this kind of view of culture emerged in anthropology as an alternative to racialist thinking. Traders, travelers, warriors, missionaries and others had been covering the globe for some time, documenting the astounding variety of human social systems with the myriad ways that people found to resolve basic problems of finding food and shelter, avoiding predation, and reproducing themselves. In part, because people with these different customs also looked very different from the Europeans who visited them, there were appeals to biology to explain custom. People were thought to behave differently because they were biologically a different—and explicitly inferior—sort of creature.
These views were challenged by the anti-racist formulations of Franz Boas and his students. Simply put, they argued forcefully that other people were not biologically different from people of European ancestry, but were different rather because they had a different culture. Culture in this sense was a name put to the total lifeway of a people. From growing food to marrying to having and raising children to governing communities to imagining the supernatural, different peoples did—not just some things—but everything differently. These ways of getting things done were routinized and regularized and learned anew by succeeding generations of a society or community. This totality of the lifeway was called culture, and the learning of it by each generation served as an effective alternative to racial determinism.
The question then became: what was the “stuff” of culture? What was culture made of? How did it get from one generation to another? How do you know it when you see it?
Answers to these questions were generated in the historical context of early ethnographic research, or the documentation of cultural patterns in different societies. In doing cross-cultural research, ethnographers looked for regularities in learned behavior that could in turn be used to make inferences about the larger systematic design for living called culture. Your job was primarily to decode and describe that design, and not to worry too much about how some people may or may not deviate slightly from the pattern. The differences within a society, especially individual differences, were just noise in the system. And it’s important to remember just how difficult it was to decode that pattern, as you were far from home, working in a second language, and trying to understand remarkably different ways of life. The more simplifying assumptions, the better.
In a sense, you could see the people in the picture as merely the space-and-time bound carriers of a cultural tradition. They happened to be there at the moment, but at another moment those particular people would be gone and you would have another set, but still carrying on that same cultural tradition. Your job was to understand the tradition, not the particular people who carried it on at the moment.
When we talk about, for example, “British culture,” we don’t really suppose it is there only because the Brits who happen to be alive right now believe and act in the ways they do. British culture was an entity in 1902 and is one in 2002 and probably will be one in 2102, regardless of the people. This gives culture a sense of “externality,” something first articulated by Herbert Spenser in the 19th century. It really does feel as though culture exists “out there.” We seem as individuals to be casting about within the confines of our own cultures. And this is something that continues to surprise students of culture in the 21st century. So, a working concept of culture must be able to account for this really quite peculiar, property of culture.
But, having said that, I’m not advocating a kind of “swamp-gas” theory of culture. It’s not out there floating around with us breathing it in (or choking on it, as the case may be). Where culture resides can only be in individual human beings. Furthermore, if we are interested in the biological impact of culture, we have to be able to trace it from “out there” to “in here.” But, we have to somehow reconcile this external quality of culture with its locus in the individual.
One way of getting at this is to stop and think about what is really important in culture and cultural differences. Is the fact that I’m wearing this suit today really important as far as my culture is concerned? Well, sort of, because I am wearing this suit, as opposed to a grass skirt or a Brazilian carnaval costume or even nothing at all. But what is probably more important than my wearing this suit is that I knew, I understood that wearing this suit was what you expected of me. We shared the knowledge that this was the right thing for the occasion. Imagine if I had showed up here to present my Burnum lecture wearing old sneakers, cut-off jeans, and a baseball cap that said Auburn Tigers on it. Probably I would not have gotten tossed out—although the Auburn part might have done me in. More likely than not, you all would have looked at me, shifted uncomfortably in your chairs, and thought something like: “what is this world coming to when they give the Burnum to the likes of this joker?” I would, in other words, have failed to live up to our shared understanding of the world in my behavior.
Now, as basic a sketch as this is, there are a couple of useful ideas implicit in this example. First, there is the shared knowledge or shared expectation. Social life—all of human life—only works because we share various understandings of the world. Everything we do we can do because of these shared expectations. One way of referring to these expectations and understandings is as “shared cultural models.” Second, I’ve just suggested how we can distinguish between culture and behavior, which actually will turn out to be quite important in the story I’m building here. As I said, we may have shared expectations regarding behavior and social interaction, but for various reasons, some people may not fulfill those shared expectations in their own behavior.
This is a very brief sketch of a theory of culture on which I have been working, in one way or another, for quite some time. But, is it good for anything? That is, does it “work?” To examine this issue, let me turn briefly to some of my empirical work. As I said, a basic observation on which all this work is founded is illustrated in Figure 3, showing how average blood pressure levels vary across different kinds of societies. Here the societies are categorized along a continuum of sociocultural complexity, ranging from the simplest foraging societies, to the most complex industrial states.
But we can break the pattern apart in more precise ways. Figure 4 shows an example of blood pressure differences among communities in Samoa, in the South Pacific, arrayed along a continuum of modernization. The term “modernization” here is just a shorthand descriptor for a variety of differences among the communities. These differences include subsistence technologies (in the traditional community, people grow yams and herd pigs for their own consumption, while in the modern community people work in factories); patterns of social interaction (in the traditional community, people are much more embedded in their extended family systems, while in the modern community people focus more on independent nuclear households); education and literacy (people in the traditional community receive relatively little formal schooling, while people in the modern community receive more); and, belief systems (people in traditional communities are embedded in a system of supernatural beliefs derived locally, while people in the modern community tend to be pulled into one of the globally institutionalized belief systems, like Christianity).
Why do people in the more modernized communities have higher blood pressures? Well, as I noted at the outset, the obvious answer to that question involves things like diet and physical activity, but taking those factors into account actually fails to explain all of the differences, although these factors clearly explain a part of those differences.
For years, one explanation for these findings has loomed large: the stress of culture change. Somehow, all of these changes in peoples’ lives are stressful, and the resulting stresses are associated with higher blood pressure. Now, this explanation is terrifically compelling, especially when linked with all of the careful laboratory studies showing how psychologically threatening events or circumstances can influence physiology. The problem, however, has been sorting out, in a conceptually precise way, just what this phrase—“the stress of culture change”—really means.
About forty years ago, there was a remarkable burst of activity in thinking about this issue at UNC-Chapel Hill, involving the epidemiologist John Cassel, the psychologist Dave Jenkins and the anthropologist Ralph Patrick. They were particularly interested in what happened to migrants from rural areas to urban areas, although the same reasoning can be applied to culture change occurring within any community. They offered the following hypothesis: the migrant to a novel setting carries with her a particular understanding of how the world works, in every sense (i.e., what it means to work, how marriages are constituted, how families treat themselves and their neighbors, how to worship—everything). She is confronted, however, with a system for which her understanding may not work. The novel and dominant culture of the new setting must be learned for everyone else’s behavior to be understood and, indeed, for her to behave in ways that are understandable to others. She must, in other words, adapt to the new setting. Even if she is successful, such adaptation can be costly. Indeed, this is precisely what Hans Selye meant by the General Adaptation Syndrome when he gave the concept of stress its first scientific respectability in the 1930’s. Adaptation is costly, and the cost of adaptation is written on the body in terms of what we call health. So, Cassel, Patrick and Jenkins argued that the less successfully the migrant culturally adapts to the new setting, the higher her blood pressure.
Unfortunately, Cassel and his colleagues had neither the conceptual nor the methodological tools to really carry this project forward—or, to continue my theme, their definition of culture didn’t “work.” But what I have introduced here—namely the idea of culture as these shared cultural models, plus the idea of a person’s relative ability to really live in accordance with those models—gives us a way of attacking the problem. Simply put, realizing shared cultural expectations in individual behavior—or what I will refer to as “cultural consonance”—is in part a measure of how well individuals are able to adapt to their social milieu. And I would take Cassel’s model much further. We don’t need to limit our thinking to situations of migration, or modernization, or culture change because each of us, in our own way, every day, is engaged in the process of sorting out, in our own behaviors, these shared expectations. We are engaged in a daily endeavor to better adapt, and one way of thinking about that process is in terms of our success at meeting those shared expectations, or cultural consonance. I hypothesize that the higher a person’s cultural consonance, the better his or her health status.
I’ve been able to examine these processes in a variety of settings over the years, including, prominently, in Alabama. I arrived here in 1978 after doing my dissertation research around these topics in the West Indies. This conventional “modernization” view of things described well what had been going on in the West Indies for some 25 years. There modernization had been driven by a single economic innovation occurring in the early 1950’s: the introduction of the banana as a large-scale cash crop. And this is typically the case in the so-called Third World. Economic change drives societal modernization.
In Alabama in 1978, I began to explore the possibility of doing research on blood pressure in the African American community, and I tended to think about the community, and its experiences in the latter half of the 20th century, in terms analogous to the modernization paradigm. Black Americans in the South were denied participation in the modern world by the American version of apartheid that we called “segregation.” But a single political innovation— Brown vs. the Board of Education in 1954, and the civil rights movement spawned by that decision—changed everything. Like an economic innovation in the developing world, this political innovation changed not just some things, but everything, for the black community. Or, like the migrants to a novel setting described by Cassel, black Americans now had a whole new world opened to them. Let me hasten to add that this is a long, drawn-out process with which we are still dealing. But, in broad outline, this is a useful way of thinking about what occurred.
What I mean literally here is that the cultural models for everyday life ceased to be primarily autochthonous creations from within the African American community, and became instead creations more of the intersection of those models with general middle class American cultural models. Not that local meanings and understanding are irrelevant, but rather that black Americans have had a whole new set of circumstances, including a whole new way of understanding the world and its opportunities and its limitations, to which to adapt. What has the effect of all this been on their health?
We know the rate of high blood pressure among black Americans is 50% higher than among European Americans (Figure 5). In my work in the community here in Tuscaloosa (and, as I will briefly mention, in Brazil), I’ve tried to examine how these cultural stresses are implicated in the process. This is how I have gone about it. On the one hand, there are the cultural models, the shared ideas about how life is to be lived. On the other hand, there is the relative success with which people can approximate those cultural models in their behaviors. The link of model and behavior is cultural consonance. Assessing and measuring a representative sample of peoples’ behaviors is what social survey work is all about. The trick has been to get at the cultural models in a rigorous and systematic way; in a way that is faithful to theory; and in a way that we can directly connect to peoples’ behaviors as assessed in the survey.
Fortunately, in the mid-1980’s, Kim Romney and Sue Weller came up with a statistical model for doing just that that they call “the cultural consensus model.” I won’t go into the details here, but the consensus model can be used to determine the degree to which people share knowledge or ideas about some phenomenon. Remember that no sharing = no culture. And, if there is sharing, we can determine the content of what is shared. Having determined what that shared content is, we can then measure the degree to which peoples’ reported behaviors actually reflect that content and see if any disparity there is associated with health status.
OK, what are the important cultural models that people must live up in order to achieve better health status? Well, obviously this is a big question, and one on which I am currently working hard. But for purposes of illustration let me pick one. There is probably no aspect of American middle class culture more highly valued than our lifestyles, by which I literally mean the kinds of material circumstances of life we can achieve, and the kinds of leisure time activities that go along with that. Thorstein Veblen placed lifestyles at the center of human motivation a century ago in his “Theory of the Leisure Class.” Now, Veblen is well-remembered for his phrase “conspicuous consumption” to describe a rather vulgar pursuit of that lifestyle among the noveau riche. He is, however, less well-remembered for this observation: “[for most people, achieving a particular lifestyle ]…is a desire to live up to the conventional standard of decency…[in the community].”
In other words, to be left behind with respect to the middle-class lifestyle in American society is to be seen to be, somehow, “indecent” as a person.
In one of our recent studies, carried out here in the African American community in West Tuscaloosa, we asked a small sample of persons to list and rate the importance of material goods and related behaviors as indicative of having had a successful life. The consensus model showed us that they agreed strongly on what that meant. Basically, it meant having a modest and comfortable, but not ostentatious, lifestyle, including such things as owning a home, a car, having nice furnishings, keeping up on current events, and, significantly, participating in one’s church. I think the inclusion of that last item speaks volumes about the sensitivity of this technique to local meanings in the black community.
We also conducted an epidemiological survey of households in the community in which we collected data on blood pressures and a variety of factors, including individual self-reports of their ownership of lifestyle items and their adoption of related behaviors. Cultural consonance in lifestyle was measured as the degree to which an individual’s reported lifestyle matched the lifestyle described in the cultural model (Figure 6).
Figure 7 shows the relationship of systolic blood pressure, which has been adjusted to take out the effects of age, sex, body mass, income and various dietary variables, and cultural consonance in lifestyle. I think the relationship is pretty clear. The closer that a person can truly approximate in his or her own behavior the shared cultural model of lifestyle in the community, the lower his/her blood pressure. Furthermore, the more distal one becomes from the model, the stronger the effect, hence the curvilinear relationship. These results suggest that low cultural consonance may be a profound and chronically stressful circumstance that, in the long run, results in poor health status.
I assume that many of you are now playing the “my favorite variable” game. This is the game in which, after presenting data, someone jumps up and asks: “But did you control for __________ (fill in your favorite variable)?” I may be especially sensitive to this game, because I have spent a good bit of time presenting these ideas to psychologists, epidemiologists, nutrition researchers, and, yes, even internists. Well, I’ve been at this business for a long time, and I’ve managed to cram most of the variables that get mentioned in the research literature into studies, and so far, controlling for these other factors fails to dislodge the importance of cultural consonance.
What creates this state of affairs, in which people do not live in consonance with shared cultural models? Well, in the African American community, cultural construction collides with structural constraint. In the best of times, unemployment rates in the black community are twice that of the white community. More than a third of households live in poverty. Median household incomes are only about 60% of white household incomes. Hence, the likelihood that an individual can achieve even the modest lifestyle goals encoded by cultural models is diminished. The tragic part of this process is that these structural constraints are a result of institutional racism and racial stratification. Over a lifetime, for a large segment of the community, people see their shared hopes and their shared aspirations, modest as they might be in a material sense, denied to them. And that denial is written on their bodies in the form of poorer health status and risk of premature death.
These ideas have pretty good legs. I’ve been working in Brazil for nearly 20 years, and have examined many of the same processes there. Figure 8 shows how, for black Brazilians, low cultural consonance leads to blood pressures higher than their white counterparts, but higher cultural consonance leads to blood pressures lower than whites.
In a sense, we have come full circle here. Remember that early in this lecture I talked about how the concept of culture emerged in anthropology as a challenge to racialist explanations of others. My work has, in a way, continued that. Now, I don’t think that many people in medicine take seriously the old idea that African Americans are at risk of high blood pressure due to a racial-genetic trait, although that idea continued to be prominent well into the 1980’s. Rather, as Tom LaVeist pointed out, there is a tendency in the medical literature to document black-white health differences without comment; however, black folks are almost always coming out worse in terms of health status: more high blood pressure, more low birthweight babies, higher stroke rates, and worse cancer outcomes. Left uninterpreted, there is a kind of unspoken inference that somehow these black-white differences are a result of racial differences. Without grappling directly with the question of how so-called “race” may actually result in poor health through sociocultural pathways, we end up reinforcing the idea that the biologically bankrupt concept of race actually has some biological validity.
But, as I have argued, if we look closely enough, we find something else going on. With blood pressure, it’s not biology in some racial-genetic sense, but rather a complex set of social structural and biocultural processes that result in the appearance that somehow race matters as a biological factor, when it doesn’t. What I hope I have shown here is that continuing the anthropological project of the 19th century—that is, using the concept of culture to debunk racialist and other kinds of wrong-headed ideas—is still an important thing to do.
To do it right, however, we need a concept of culture that works. We need a concept of culture to help us to deconstruct the surface appearances of life. As the Dutch psychologist Ap Appel noted: “The final discovery a fish can make is that of water. It does not know what it means to live in water until it is lying on the counter of a fish shop. Similarly, people do not realize to what extent their behavior…is rooted in the culture in which they live.”
By explicating those links of culture and behavior, we can, I hope, both improve our theoretical understanding of the world, and maybe make it a better place to live.
*This essay was prepared as a lecture on the occasion of receiving the Burnum Distinguished Faculty Award.