The behavioural research agenda in global health: an advocate's legacy.

Two of the disciplines that have come to infuse global health with some of its current vibrancy are epidemiology and anthropology, disciplines that focus, in one way or another, on the causal importance of human behaviour in socio-political, ecological, evolutionary, and cultural context. One of the little-known stories in the history of twentieth century global health involves the works of a number of pioneering interdisciplinary scholar-practitioners, who urged a synthesis of epidemiological and anthropological perspectives in what was then called 'tropical medicine'. One of these pioneers was Frederick L. Dunn, who forwarded lasting insights about the importance of human behavioural research in understanding infectious disease. This article provides a historical-biographical accounting of Dunn's contributions to public health in the second half of the twentieth century, arguing that his persistent advocacy of multi-level, social behavioural research and his notion of 'causal assemblages' were critical in the early development of the twentieth century discipline of global health.

Poor medicine for poor people? Assessing the impact of neoliberal reform on health care equity in a post-socialist context.

Driven in part by a resurgent interest in social inequality and health, and in part by increasing scrutiny of the social and health consequences of neoliberal economic reform, principles of health equity and social justice, the centerpieces of the Health for All strategy drafted at Alma Ata in 1978, are once again at center stage in global public health debates. Whether and how equity in access to health care can be maintained in a context of market-based health sector reform has not been systematically addressed, particularly from the perspective of local communities. This paper will explore how health reform affects health care in post-socialist Mongolia. Through a mixed-methods household-based study of low-to-middle income communities in urban and rural Mongolia we find that despite explicit and concerted efforts to reduce inequities, the reform system is unable to provide equitable health care either vertically or horizontally. Emphasis on privatization of the secondary and tertiary sectors of the system, coupled with deployment of universally-accessible, but from a clinical standpoint, limited, version of essential primary care, produces a fragmented system. Particularly for the vulnerable poor, access to services beyond the primary care system is compromised by financial, opportunity, and informational cost barriers. This research suggests that new models of health reform are needed that will effectively bridge the growing gaps between public and private resources, primary and secondary and/or tertiary care, and clinical and public health services.

The health transition, global modernity and the crisis of traditional medicine: the Tibetan case.

The epidemiologic and demographic consequences of the health transition, coupled with worldwide pressures for health care reform according to neoliberal tenets, will create new opportunities, and well as new problems, for organized systems of indigenous medicine. Spiraling costs of biomedically-based health care, coupled with an increasing global burden of chronic, degenerative diseases and mental disorder, will produce significant incentives for the expansion of indigenous alternatives. Yet this expansion will be accompanied by pressures to rationalize and modernize health care services according to the structurally dominant scientific paradigm. Without concerted effort to maintain native epistemologies, indigenous medical systems face an inevitable slide into narrow herbal traditions and a loss of those elements of diagnosis and therapy which may be the most valuable and effective. Analyzing the case of Tibetan medicine and other Asian medical systems, I show how this process occurs and how it is resisted. I conclude by discussing the policy dimensions of this problem.

Imagined lives, suffering, and the work of culture: the embodied discourses of conflict in modern Tibet.

This article explores the cultural epidemiology of rlung ("loong") disorder among Tibetans living in the cities and towns of the modern Chinese state of Tibet. Rlung, glossed as air or wind, is the most important of the three humors of the classical Tibetan ethnomedical system. Considered by Tibetans to be contingent upon multiple social, emotional, and religious phenomena, rlung disorders are fertile ground for the development of etiological discourses that incorporate the social and political crises that are part of the rapidly changing Tibetan plateau. In this essay I locate rlung disorder in a confluence of Tibetan ethnomedical constructions of the mind-body-universe linkage, in which rlung stands as the chief symbolic mediator, with ethnic conflict, rapid economic development, and the localization of global debates over Tibetan suffering and human rights.

The transformations of Tibetan medicine.

This article presents a cultural and historical analysis of 20th-century Tibetan medicine. In its expansion into the state bureaucracy, Tibetan medicine has acceded to institutional modernity through transformations in theory, practice, and methods for training physicians. Despite Chinese rule in Tibet, however, Tibetan medicine has not yielded completely to state interests. With the collapsing of the traditionally pluralistic Tibetan health system into the professional sector of Tibetan medicine, contemporary Tibetan medicine has become to the laity a font of ethnic revitalization and resistance to the modernization policies of the Chinese state. These processes are particularly evident in the elaboration of disorders of rlung, a class of sicknesses that, collectively, have come to symbolize the suffering inherent in rapid social, economic, and political change.

Recent developments in alcoholism:the workplace.

We examine the results of recent research that considers the relationship of the work environment to drinking behavior and problems. We bring the concept of culture to the foreground in this discussion, and show that much of what alcohol researchers term as work-related risk factors are, in effect, best understood as aspects or dimensions of cultural processes which operate in complex organizations. We identify and review four perspectives on alcohol use in occupational contexts that highlight these cultural processes at work: (1) the development of organizational norms with respect to drinking, definitions of problem drinking, and mechanisms of social control; (2) working conditions that produce in some workers experiences of powerlessness, alienation, or stress which are in turn alleviated by drink; (3) the interaction of cultural factors external to the workplace--regional/national, community, ethnic, and religious--with organizational cultural norms which affect alcohol values, beliefs, and behaviors; and (4) processes that underlie the development of occupationally based drinking subcultures.

Ethnographic explanations for the clustering of attendance, injury, and health problems in a heavy machinery assembly plant.

We examine the clustering of attendance, illness, and accidental injury problems in a large unionized manufacturing plant using both quantitative and qualitative methods. We find that the distribution of workers into problem groups is related to 1) conflicts over seniority, 2) physical stressors and their influence on perceived desirability of certain kinds of jobs, and 3) organizational conditions and environments congenial to the development of distinct occupational "subcultures." We suggest that the case study approach we apply in this paper is critical to the design of programs of preventive intervention and complements the more commonly applied multiple-site and individually focused, survey approaches.

Migration, changing gender roles and stress: the Samoan case.

The impact of migration and social change on male and female role expectations is examined in an urban Samoan community. Expanding role expectations and role conflicts in the urban context are linked to differential experiences of stress by gender, which are in turn examined with respect to the health outcomes of arterial pressure, a measure of physical health status, and a psychosomatic complaint index.

Men, blue collar work and drinking: alcohol use in an industrial subculture.

We present the findings of research designed to identify the social and environmental precursors of heavy drinking in a population of white assembly-line workers. Using a primarily qualitative approach, we examine alcohol use in relation to the sociocultural characteristics of individuals' community and workplace environments and their early-life socialization experiences. The sample consists of 30 men--15 heavy drinkers and 15 moderate drinkers--who were drawn from the workforce of a large durable goods manufacturing plant that closed in 1982. Workers' accounts of their own and coworkers' drinking suggest that a heavy drinking subculture existed in the workplace. Within this culture, drinking was a normal part of work life, and served to improve social relationships, reduce boredom and dissatisfaction, and to express solidarity in defiance of management rules and working conditions. Membership in this subculture, we believe, was most important for those men who had no interests or social involvements outside the workplace. We compare the characteristics of workers who chose to join this subculture (the heavy drinkers), with those who did not (moderate drinkers). Factors that predicted involvement in the heavy drinking subculture were: a sociocultural background where heavy male drinking was normative, lack of extra-work social resources, and leisure activities restricted to coworkers and work-related contexts. Conversely, moderate drinkers tended to come from moderate drinking backgrounds, and had considerable community and social group involvements that included family and peer networks to the virtual exclusion of coworkers.

Heavy and problem drinking in an American blue-collar population: implications for prevention.

This paper presents the findings of a prevention-oriented research project designed to identify the familial and socio-environmental precursors of heavy drinking in a blue-collar population. Using an ethnographic and primarily qualitative approach to data collection, this study examines alcohol use and drinking behavior in relation to both the family as a unit, as well as the sociocultural context in which it is embedded. It reports primarily on features of cultural, workplace, and community environments that are related to heavy or moderate drinking in the subject population. The sample consists of 30 families, 15 where the father is a heavy drinker and 15 where he is a moderate drinker. The sample was drawn from the workforce of a large manufacturing plant that closed in 1982. The social organization of the workplace, including the important factors of job alienation, job stress, inconsistent social controls, and the evolution of a 'drinking culture,' is implicated by this research to be the primary vehicle for promoting high levels of alcohol use. Although the role of the workplace in encouraging certain alcohol behaviors was predominant, the data suggest that it alone may not be sufficient for causing alcohol problems. In particular, the central importance of drinking in work-related social contexts and the relative permissiveness of the work environment was found to promote heavy drinking among individuals who were of sociocultural backgrounds where heavy drinking was permitted or even encouraged; reported a lack of effective male role models when growing up; and restricted leisure activities to male-oriented peer groups most often met through work-related contexts. Conversely factors that appeared protective of developing high-risk drinking patterns were family religious involvement, and participation of fathers in non-work related social groups that usually involved their wives and children. We conclude the paper by offering suggestions as to how these findings might lead to constructive strategies for the primary prevention of alcohol problems in the context of the workplace and community.

Migration and biocultural adaptation: Samoans in California.

The consequences of migration for the Samoan population of California are discussed within the context of other studies focusing on Samoan native and migrant populations in Samoa and Hawaii. The social, cultural and economic characteristics of California Samoans are described and data are presented for body morphology, blood pressure, psychosocial stress and social support, general morbidity patterns and mortality rates for 1978-1982. Although the nature of disease risks appear profound in this population, particularly patterns of extreme obesity and psychosocial stress, mortality rates for heart disease and stroke are less than might be expected among other American groups. Such unexpectedly low mortality rates may represent the relatively healthy experience of older cohorts of migrants, or be a result of proportionally few individuals having lived long enough in California to develop cardiovascular and other chronic disease that have lengthy natural histories. We postulate that at present Samoan social structure, particularly the high status that accrues with aging in traditional Samoan society, may act as a buffer for the risk factors we observed and their expected outcomes. If so, the U.S.-born Samoans who are currently passing through childhood and early adult years with progressively less awareness of Samoan values of family and social structure will exhibit the same risks we describe here, but lack the available social buffers that currently exist for their parents.