Local moral worlds interpersonal basis of illness experience

Ethnographies—hundreds of them, including many on psychiatric topics—demonstrate, with great consistency, that most people and most patients are not isolated individuals but rather live their lives as active members of local worlds. By local worlds, ethnographers mean villages, neighbourhoods, networks, and families, as well as particular social institutions, including hospitals and outpatient systems. Ethnographic research illustrates the interpersonal processes of communication, negotiation, and contestation that make up everyday experience in local worlds everywhere. Rarely are communities or even networks homogeneous, as was erroneously thought to be the case earlier. Rather, local worlds are differentiated by class, ethnicity, gender, age cohort, political faction, religious ties, and still other social differences. That is why one must be extremely cautious about characterizing a local world as if it were one distinct thing. But what does hold for each and every local world is that there are crucial things at stake that orient the attention and actions of participants. What is at stake, most at stake, may be shared (status, resources, survival, transcendence), but it also can be as distinctive as the different meanings of ultimacy that make religions distinguishable from each other.

Illness experience and experiences of treatment are as much caught up in these transpersonal processes of agonistic and antagonistic engagement over what is at stake in experience as are experiences of normality. Thus, for anthropology how a person's illness is encountered, coped with, understood, and lived is simply crucial for understanding the illness and the treatment. It is for this reason that anthropologists write about the social course of illness: meaning that local worlds shape the course of illness so thoroughly that the same disease process (diabetes, AIDS, depression, schizophrenia) can take different trajectories. When sick people go for treatment, who they first seek out, whether they comply with the therapeutic regime, how they assess their experience of treatment—all are in one way or another influenced by what is most at stake for communities, families, networks, and individuals. The anthropological contribution here is to highlight the processes through which individuals relate to collectives. Thus, Estroff(2) shows that collective and individual definitions of identity affect how schizophrenic patients live their schizophrenia as an illness identity, which in turn affects their careers as patients and their experiences in other domains (family, workplace, etc.).

Another example of the difference between anthropological and psychiatric approaches to human conditions is the way the two disciplines understand suicide. In American psychiatry, at least, it is widely accepted that most of the time suicide occurs in the context of depressive disorder, and that that disorder as well as individual impulsivity are the principal determinants of suicide. Anthropological understandings are derived from the study of suicide as a collective experience. Hence, anthropologists note that suicide rates index a variety of social changes, most notably economic depression and political violence. In China today, the rate of suicide is at least twice that of the United States, and possibly may be three times as high. Yet rates of depressive disorder in China are very low by international standards; indeed the most recent epidemiological data from China suggests the rates of depressive disorder may be as much as five to 200 times less than in North America. Hence it is highly unlikely that depression can be the major determinant of China's enormous rate of suicide. Moreover, suicide in China is unlike suicide in the rest of the world because it is more common in women than men. Of all suicides in the world, 40 per cent occur in China (which accounts for 20 per cent of the world's population) and an astonishing 50 per cent of all reported female suicides occur there. Rural women from 15 to 25 years of age and men and women over 55 years of age are most at risk for suicide.(3) Recent research (psychological autopsies in the context of village-based epidemiological studies) suggests that in most instances there was no evidence of serious depression. Rather, family conflicts and other well-documented interpersonal problems were found to be present. Furthermore, analysis of suicide notes suggests that in many instances suicide was an act of social resistance against oppressive patriarchal conditions such as forced marriage, pressures following failure to produce sons, infanticide, abusive husbands, husbands who took second wives or mistresses, and so forth. Marginalization and relative powerlessness as social positions correlate better with suicide than does psychological status. Here societal and individual perspectives lead to vastly different interpretations of the determinants of suicide. The Chinese concept of 'loss of face' (loss of embodied moral status, lianmian) points to interpersonal connections between the moral and the emotional levels of experience that seem particularly important for understanding suicide (for the reason that many suicides in China follow serious loss of face and can be viewed as a desperate but still acceptable means of regaining face), and perhaps not only in China.

Altruistic suicide is also valued.

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