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My interest in the concept of risk arouse from reading the paper by Sandra Gifford (1986) on breast lumps and the ambiguities of risk. While reading her article, I recognized many of the ambiguities I experienced in clinical practice, and I was stimulated to further reflections on the concept. In health matter the concept of risk is indeed central, being related to the understanding, interpretation and avoidance of a source of suffering.
I think that to look at risk from an anthropological perspective, a part from being interesting per se, will improve my understanding of the factors at stake and help my future work, in clinical practice as well as in preventive medicine and public health.
Life is uncertain, misfortune can strike at any moment, sometimes with disruptive consequences, it can change people life plan. It is part of human condition having to deal with contingencies and uncertainty, humankind has been managing such undefined situation, the attempts to control it have been creative and challenging. Uncertainty about possible misfortunes has brought about the concepts of danger and risk, in the attempt to define and give a name to the incumbent possibilities of "something going wrong" and in the effort to control the outcomes.
In health, the definition of risk is related to the about causality of diseases, the lived experience of suffering and the possibilities of action. The approaches to analyze the concept of risk are many, I will focus my discussion on the definition and management of risk, that means on the relationship between knowledge, experience and action.
My arguments are based on the consultation of the literature and on the comparison of a case from USA, presented in the article of Gifford (1986) on breast lumps and a case from Zululand, taken from the ethnography by Harriet Nugabe (1977) "Body and Mind in Zulu medicine". I will do "armchair anthropology", using the works of other people to explore differences and similarities between two cultures. The literature on risk is extensive and, by no means, my review is complete. I mainly used texts that were accessible to me, that were of use for my line of thought and that I knew through my recent studies. I will analyze the concept of risk in Zulu culture as presented in the ethnography by Ngubane, my main objective is to explore how risk is defined and dealt with in Zululand, I will use the case study on risk in USA, presented by Gifford as supporting reference.
For the purpose of my writing I will use the terms risk and danger for the same concept respectively in the American positivistic and the Zulu cosmological "traditions", where for tradition I intend a system of thoughts, knowledge, beliefs and values that shapes the experience and action of a group of people in a particular time.
In this paper I will explore different issues. First, I will analyze the concepts of risk/danger in their historical and anthropological understanding. With a discussion on the epistemological basis of African and Western thoughts, I will present what, to my opinion, underpins differences and similarities in the conceptualization of risk and danger. Second, I will analyze the concepts of risk/danger in relation with health. I will present two concrete examples, to examine the factors influencing definition and management of risk in two different contexts. I will refer to two epistemological perspectives and to one "experiential" approach. Third, I will discuss how "specialists" are involved in the process of definition and management of risk/danger and how this involvement allows for sharing responsibilities and anxiety related to uncertainty. Finally, I will conclude the discussion with some general remarks.
Uncertainty has always been there, part of our daily life, resulting from the human experience of misfortune. The concept of danger is old, it represents the experience of disruptive forces and the possible cause of human suffering. The concept of risk came to being in the sixteenth and seventeenth centuries, in relation with western explorers and travelers. Later, it was used for financial enterprises of banking (Giddens 1999:21) and gambling. Introducing the concept of risk means considering "the probability of an event occurring combined with the magnitude of losses or gains that might be entailed" (Douglas 1992:40). To the concept of danger was added the measurement of chance with the prospect of being able to predict event. Mary Douglas, famous for her work about dangers, wrote, twenty years later, a book about risk (1982) and analyzed modern western concepts. She reformulated dangers in the language of risk and probability. Risk and danger are the same concept, expressed in two different paradigms. Probabilistic thinking, implicit in the concept of risk, implies ignorance and uncertainty about the results, but, as Hayes (1992) underlines, now risk has been associated only with negative outcomes. Risks grow in number, this sounds awkward in a world where the advances of science promised increasing control over events, nowadays, risk has become the way to "describe relationships between uncertain knowledge and unwanted outcomes" (Gifford 1986).
Risks are many and to allow for action, we should select among them. This selection takes place through a cultural process, driven by political and moral statements. By establishing what is risky, we decide who is responsible, expressing a moral judgment. Through a careful use of the language of risk we can present situations that differ in "pointing the finger of blame and imply responsibility for remedial action" (Nelkin D. cited in Hayes 1992). Dangers are selected between forces that can disrupt social life: through pollution beliefs and taboo behaviors, these forces are kept under control. Risks are studied and measured, accepted or rejected on the basis of the interests of different groups and used for casting the blame of the unwanted outcomes (Douglas 1982, 29-40).
I will now briefly discuss two epistemological frameworks, this diversion will help to understand the following point about risk in health. One framework is prevalent in African societies, I will call it African framework, and the other one is present in Europe, I will call it Western framework. I am making a gross generalization in talking about Africa and Europe as two homogeneous whole, but it is useful for my argument and I think that general patterns indeed exist within the two continents, at least this is the impression I had from reading ethnographies on sub-Saharan Africa and Western Europe.
Robin Horton (1967 and 1982) wrote two very interesting analysis of African and Western thoughts, especially regarding epistemological issues; the fifteen years gap allowed the author to collect all the critics to his arguments and to revisit his hypothesis in the light of new works . From these papers I will extrapolate concepts that result useful for my purpose, that is understanding the concepts of risk and danger.
Both epistemological thoughts share a "quest for explanatory theories [that] is basically a quest for unity underlying diversity; .....for order underlying apparent disorder" (Horton 1967:51), both create a "causal context" that transcends the common-sense, but both "take their departure from the world of things and people and, ultimately return us to it" (Horton 1967:59). In both frameworks there is the attempt to explain and order the outcomes of experience, through a model that can be useful in guiding action.
Western knowledge has been committed to positivism since the "Scientific Revolution". Through empiricism, science promised a total explanation of reality, that is there for us to be discovered. The validation of scientific knowledge come from its own methods: the verifiability or the more modern falsification criteria are the basis for testing scientific hypothesis through experimental observations (Wulff et al. 1995:36). Western thought, claiming to be scientific, was considered to be free from moral stances, based on objective observations and aimed at explaining a "material" reality. From the work of critical anthropologists and other social scientists we were shown that science, as well, is embedded in cultural context and expresses the ideology and morality that produces it.
African framework of epistemology has been qualified in many ways, following the different interpretations of the external puzzled observers. Supernatural agents were often presented as the focus of the explanatory theories originated in the African continent, but as underpinned by Horton (1967:53-54), the supernatural agency "very commonly involves references to some events in the world of visible, tangible happening". The causal context is provided by observations and experience, the reference to supernatural entities is used to "link events in the tangible world (natural effect) to their antecedents in the same world (natural causes)". This is very well exemplified in the theories on causation of diseases, as example: somebody's disease (natural effect), is explained by witchcraft (supernatural force), but the use of witchcraft is motivated by envy or jealousy, due to the behavior of the sufferer his/herself or his/her kin (natural cause).
I tend to support an interpretation of the African framework as "externalizing" (Young, 1983), in which the causal relations are searched in "agents, events and motives" that can be located outside of the object experiencing them, often in the social network. This makes the social and moral dimensions of knowledge more visible and straightforward, at least to the outsider observer. The main difference than is where the causal relation are localized, not so much the use of mystical, supernatural explanations.
Theories come from experience, and their validation depends from "tradition": the framework, passed down from generation to generation through oral transmission, with constant adjustments due to changing contexts, is always projected back to the ancestors. This continuity gives to it "the age-old, time-tested" authority, and also explain the apparent "traditional" character.
Modern researchers working in medical anthropology (Pool 1994, 239 & Ventevogel 1996, 135-137), underlined the fluidity of African knowledge, in which culture and thoughts are produced and performed, evoked by the contextual situations. The oral tradition makes knowledge more flexible and adjustable to different situations, but the lack of written references, masks the "striking changes" that accumulate through generations, giving to knowledge an "absolute and timeless validity" (Horton 1967: 180).
Finally, I would like to stress that theories are formulated in the attempt to explain, predict and control reality and, of course, misfortune, the feared negative outcome of uncertainty. The threat of misfortune has influenced thoughts and actions of human beings. In the struggle to control and overcome the outcomes of an unknown future, humankind has been active and creative, as Whyte (1997:18) affirms, presenting the thoughts of Dewey, that "..celebrates rather than deplored uncertainty, because he believed that through interacting with our ambiguous and troublesome surroundings we refine our abilities to imagine, plan and control". The quest for certainty is a quest for action and is through this possibility that the concept of risk starts to make sense.
Sickness is a common experience and among the most feared misfortune. To prevent the fearful situation of bad health, we need to know the determinants of illness, what puts us at risk, what makes us vulnerable. Here the function of knowledge comes into play, how we conceive the relation between reality and its manifestations: the experience of illnesses is interpreted, to establish the causal link between the ill condition and its determinants and to be transformed in preventive action. Once the theories of causality are applied, the definition of risk is established and available for the moral stance and the attribution of responsibility and a plan of action can be plotted.
I will go back to the examples to clarify this concept. Sandra Gifford in her article on the ambiguities of risk presents the case of a benign condition, the fibrocystic breast, transformed through the methods of epidemiology, in a risk and through clinical practice in an entity, a condition of ill-health, to allow practitioners and women to manage the uncertainty related to breast cancer. Breast cancer is a common "misfortune" in USA, it is the leading cause of death for women between 40 and 44 years; despite the intensive research, there are no definitive answers on its causes. But epidemiology, through population study and statistical methodology can trace relationships between the exposure to various factors and the appearance of cancer. Through epidemiology "the notion of probability is introduced, to describe the given uncertainty concerning suspected relationships and the concept of risk replaces the concept of cause" (Gifford 1986). However, the epidemiological language of risk is ambiguous, "it depersonalizes the causes of disease" and does not respond to the quest for action. Therefore, at clinical level other meanings are superimposed on risk, which make sense for the clinician and for the women: it results that a possible association, (fibrocystic breast and cancer) becomes a new entity, that can be experienced and dealt with. Action is now negotiable between the practitioner and the woman, both dealing now with the new shape of the uncertain cause of breast cancer.
Harriet Ngubane presents thoughts and practices of the Nyuswa-Zulu people concerning health and disease, the causation of diseases is discussed at length. The system of knowledge allows for varied explanations of illness, basically referring to altered balance with the ecological and social environment. "Good health means the harmonious working and coordination of the universe" (Ngubane 1977:28). People adjustment to their surroundings should be in balance: wild animals, birds, lightning, foreigners and people coming back from outside Zululand, can bring with them dangerous substances that are noxious for health. These foreigner substances are left on the way as "tracks" and can be "picked up through inhalation or through contact either by touching or 'stepping over'" (pp 25). The avoidance of those tracks and the protection through administration of medicine, are the actions taken to neutralize the risk. Some people are more vulnerable to the danger of tracks: infants, strangers, pregnant women, people in state of pollution (the bereaved, menstruating women, etc.). Also in this case the undefined uncertainty related to the threat of environment becomes something people can deal with. Action is now possible through preventive medication or by discharging the poisonous substances on the way of someone else, who will bring it away.
The two cases can be analyzed focusing on the three different stages of definition of risk: knowledge, where the observed events are transformed into theoretical models and the causal links are established; experience, where the world of everyday life gives a meaning to what happens around us and where the body, being the "existential ground of culture" (Csordas 1990), is the place of compilation of experience and transformation of knowledge. Finally, action, that brings about new experiences and allows for control of the anxiety caused by uncertainty. I will analyze these three stages, with references to the two examples, to describe how they are elaborated in the different contexts.
In both examples is present an attempt to translate the results
of experience into useful theories, that allow ordering of events into causal
relation.
In Zululand the experience of illness, associated to the experience of contact
with new environments or outsiders, is systematized into environmental danger. Green
(1999:65) in his study on indigenous theories of disease causation, underlines how
frequent is this model in southern Africa, described also in other ethnic groups, in
Swaziland and Mozambique.
The possibility of diseases, following the contact with unfamiliar objects or
persons, is transformed into tracks, "undesirable elements in the atmosphere"
(Ngubane 1977: 25), that can enter in the body and cause illness. Through this
transformation, the definition of risk is possible, the groups at risk are
designate: those who are strangers to the environment and those which are polluted,
run the main risk.
In the western setting, where very little is known on the etiology of breast
cancer, the scientific methods of epidemiology, collect the experience of high
mortality in middle aged women, and relate it to a variety of risk factors. The real
contribution of fibrocystic breast condition in cancer is not clear, epidemiologists
had alternate results in establishing relationships between the two conditions, but
"there does seem to be a general association between the two" (Gifford 1986).
Epidemiology studies populations and associations of events, through epidemiological
knowledge risk becomes defined by "states of health which are located outside of any
one particular individual; it depersonalizes causes of disease" (Gifford 1986). The
mechanical model of disease used by clinicians, with "internalizing" (Young, 1983)
pathological process, further transforms the epidemiological association into a
clinical entity, that can be palpated, monitored and even biopsied, allowing the
uncertainty of knowledge, clinical practice and life to be acted upon and
controlled.
As source of knowledge and guidance to action, experience is
central in my analysis of risk. I will now focus on the lived experience of everyday
life of American and Zulu people.
For the purpose of discussion I will refer to some concepts belonging to the
paradigm of phenomenological anthropology, a fragmented movement that grounds its
studies in the "lifeworld", an intersubjective world of experience and
interpretation, where the body is the "existential ground of culture" (Csordas
1990). As in the argument by Marcel Mauss (in Csordas 1994) "the body is as the same
time the original tool with which humans shape their world, and the original
substance out of which the human world is shaped".
As underlined by Gifford (1986), risk perception for women with a diagnosis of
benign breast disease is very different from that of epidemiologists, that define it
with statistical methods, or clinicians, managing it as a clinical entity. The
phenomenological approach, "gives priority to understanding the lived experience of
risk" (Gifford 1986). The effects of ambiguous information and of uncertainty have
to be considered to understand women's perception of risk. To deal with uncertainty
and for risk to be real , it should be transformed into a subjective experience,
should be embodied in something experienciable, a physical condition that can be
lived.
I will analyze tracks and environmental dangers of Nyuswa-Zulu people following
the same approach. The indeterminacy of possible dangers from the environment is
objectified in tracks through local knowledge, this transformation is taken over by
lay people and, at experiential level, those dangers become dangerous substances,
something belonging to the world, to the realm of bodily experience. These dangerous
substances, if picked up can cause disease, that can be treated by removing and
discarding them:
"it is said that, to keep the immediate environment clean, cross-road and
highways are popular places for the discarding of dangerous substances. Since these
places are frequented by travelers, the undesirable substances would be attached to
the latter and so carried away from the territory". (Ngubane 1977:26).
The experience of environmental risk, that is uncertain, not defined, is
transformed in tracks, something with a shape, that can be embodied: the word
itself, umkhondo, is used to "describe a visible track on the ground or the
invisible track 'picked up by dogs'" (Ngubane 1977:25), something that belongs to
everyday experience.
Once again it seems that the same process is at work: the transformation of
"objective knowledge", (based on the culturally informed elaboration of experience)
into an embodied shape, something that can be experienced in the body and through
the body and as such is liable to manipulation and control. This process is socially
and culturally informed, that means it refers to different frameworks of though and
to different perception of the everyday world. Through a differently informed but
similar process, two different shapes for the indeterminacy of risk are
experienced.
For this last part of analysis I will refer to the work of
Whyte (1997), whose ethnography about "the pragmatics of uncertainty" highlights the
importance of action, central point in the study of uncertainty. This kind of
analysis, moves the focus from the individuals and their lived experience to a
broader context. Action is the result of knowledge and experience, is a "response
adopted from a common 'conversation' within a shared historical condition" (pp.
226), as such it implies a negotiation between knowledge, experience and practices.
Using this "pragmatic" approach and referring to the previous two examples, I will
examine the actions taken in the two different contexts.
In her article, Gifford (1986) presents the negotiation between clinicians and
patients in the management of risk. She stresses the lost of control over risk
management by the women, through "medicalization". The risk, that from
epidemiological knowledge has been translated into clinical practice and has been
loaded with the uncertainty of the clinicians' own experience, is now a clinical
entity, ready for manipulation. This need for control can lead to the extreme
solution of prophylactic mastectomy: some surgeons suggest the removal of the benign
fibrocystic breast, "in order to create a more certain physical condition" (Gifford
1986). Women use different strategies to overcome the feeling of uncertainty: some
will accept the medical advise for removal, gaining a more certain status of
ill-health; other will deny the risk, sometimes with bad consequences.
Among Zulu people various strategies are applied to "establish and maintain a
form of balance with the surroundings" (ecological and social) (Ngubane 1977:26).
Everybody undergoes periodical medication, especially children, who have to build up
immunity to the environmental dangers. Dangers, especially for those in state of
pollution, highly vulnerable, can be reduced by avoiding tracks, that means to stay
within the well-known boundaries of the community, and keep away from contacts with
foreigners and wilderness. In both cases the action is directed by the definition of
risk and its experience, it is aimed at averting dangers and preventing the
consequences of exposure to risk.
For preventive purpose, a specialist can be consulted, either a doctor or a
diviner, who has the task to translate the theoretical model of causation into a
practical behavior for prevention. This brings me to the last part of my
discussion.
I want to explore the involvement of "specialists" in dealing with uncertainty, and how their intervention is used by people to share the afflictions of uncertainty.
I will make use of insights from Feierman (1985), whose work on the social roots of healing in Africa, addresses the question of control on the healing process. He maintains that those who are in control of the healing process and as such define the causal links, have control also "in shaping ideology" (pp. 75), thus on the meaning of life. Starting from this idea he pursues three hypothesis: the control is in the hands of either culture itself, or the healers or lay people. He finds evidences of the three possibilities in different ethnographies on African people, but finally he seems to come to the conclusion that what should be considered is the total aspect of social institutions and ideology of a society and this "breaks down all the barriers between the study of healing and the general study of social life" (Feierman 1985:83).
For my purpose I will consider medical practitioners, both Western biomedical doctors and African diviners and healers, as specialists, not so much in controlling the process of healing and thus the meaning of life, but as being in a special position in the negotiation between people and uncertainty. They enjoy their position because they are translators of knowledge, from the theories to practice; they are involved in defining the shape of risk. "Divination is the formal occasion for making uncertainty explicit and for developing the ideas that form plans of action for dealing with it" (Whyte 1997:60). Through action there is a relief of anxiety, of the tension determined by misfortune or uncertainty. In this position they hold a certain power, they enjoy a special status in the community, but at the same time, they have to share uncertainty with their clients, part of the responsibility to deal with the unknown.
The sharing of uncertainty, through a process of negotiation, is very well illustrated in the paper of Gifford, in which she describes how "objective risk (knowledge) and lived risk (responsibility) represent two dimensions of clinical risk experienced by medical practitioners" (pp. 226) and when she pinpoints at medicalization of risk as a lost of control of women on their own health.
In Zululand, Ngubane explains us, the diviners are women and the doctors are men, the first are consulted "to find out the causes of trouble" (pp. 104), the latter for treatment. In the case of Zulu practitioners, the sharing of uncertainty is not explicit in the ethnography, but it seems, and this is described in other parts of Africa, that the role of the clients is more active. Wyhte (1997) writes that the diviner and the clients undergo a "joint venture" (pp. 73), the clients have more autonomy and power in the negotiation for the control of uncertainty.
In both African and Western examples the involvement of specialists guarantees a more effective management of uncertainty, their intervention helps to apply the theories that explain the unknown and to find a shape for the undefined, this, in turn, mobilizes action against misfortune. The different frameworks and power relations determine the respective involvement of specialists and clients in different cultural contexts.
This short exploration in the concept of risk, and its application for prevention of misfortune, was an opportunity to review the relationships between knowledge, experience and practice. I could appreciate some common features of two cultures that apparently seem very far from each other and I learned, from the differences, about the amazing richness of possible solutions to problems that everywhere challenge human creativity.