- Email: [email protected]
FIJAc: Fright and illness in highland Yemen
Sm. Sci. Med. Vol. 28, No. 4, pp. 381-388. 1989 Printedin Great Britain. All rights reserved
FIJA’:
FRIGHT
AND
0277-9536189 $3.00 + 0.00 Copyright C 1989 Pergamon Press plc
ILLNESS CHARLES
7446 W. 91st Street,
F.
IN HIGHLAND
YEMEN
SWAGMAN
Los Angeles,
CA 90045. U.S.A.
Abstract-Sudden fright. Sja”. has played an important role in the traditional explanatory models of illness experiences in highland Yemen. Fijac is quite similar to other examples of the fright illness taxon in that it is a folk-illness category that is attributed to a wide variety of underlying conditions. It is argued that given the extremely labile symptomatology, fija’, like other examples of the fright illness taxon, does not constitute a culture-bound psychiatric syndrome. Based on analysis of case studies and preliminary survey data, fijac appears to be much more common among folk etiologies offered by Yemeni women than men. It is suggested that this social profile might be explained by changes in the distribution of medical knowledge in Yemen. With the rapid rate of social change and the increased exposure to cosmopolitan medicine resulting from internal development of cosmopolitan health care and international labor migration, men have supplemented their traditional explanatory models with alternatives drawn from cosmopolitan medicine. Succumbing to illness as a result of fright is contradictory to the male ideal of the courageous tribesman; alternative explanatory models that do not challenge this ideal self predominate. By contrast, the Yemeni value system defines women and children as vulnerable and weak; therefore, being subject to the impact of fright is consistent with youth and the cultural definition of the female self. Kqv w>ords-Middle
East, Yemen,
folk illness, medical anthropology
This paper addresses two basic questions in the analysis of folk illnesses associated with fright: is it still useful to continue to employ the construct ‘culture-bound psychiatric syndrome’ in the analysis of conditions subsumed under the ‘fright illness taxon’? and what factors influence the distribution of such fright illnesses in a society? In participating in the debate I will present some preliminary data from highland Yemen that supports the growing body of opinion that many of the fright illnesses should no longer be considered as culture-bound psychiatric syndromes (11. In this paper it is also suggested that questions about the distribution of fright illnesses in society might best be answered by examining factors that influence the distribution of medical knowledge in society. As a prelude to the discussion it is important to briefly review previous treatments of these problems. Fright and illness: contrasting perspectives
Sudden shock. startle, or fright has been associated with illness in many cultures. While the importance of culture in shaping such folk illnesses is universally recognized, a basic question about the role of culture in the illness process, whether it “causes something locally unique to happen or is it merely the symbol system for elaborating ubiquitous pathological processes,” remains of interest [I, p. xiii]. Among the adherents to what Hahn [2] has labeled the ‘inclusionist’ perspective (who hold that all illness, including the ‘culture-bound syndromes’ are an interaction of cultural, natural, cognitive and psychodynamic factors) there is secondary debate over the status of specific illnesses categories, and whether or not they constitute definable syndromes. With regard to conditions generally included in the fright illness taxon the debate among the ‘inclusionists’ is between two
contrasting perspectives, one which hypothesizes that they constitute unique and clinically definable classes of disorders-culture-bound syndromes [3,4], and the other that interprets them as culturally constructed illness categories that are ascribed to a wide variety of underlying physical conditions [S-7]. While the assertion that many of the conditions included in the fright illness taxon constitute culture-bound syndromes has been effectively challenged on epistemological grounds (81, a valid argument against defining such fright illnesses as ‘syndromes’ may be made on empirical grounds as well. Some of the most significant problems for the analysis of fright illnesses as culture-bound syndromes stem from the apparent contradictions scattered throughout the ethnographic record. For example there is often little local consensus about illness diagnosis and labeling. Ethnographers typically encounter an array of people who are recognized and labeled as ill; sufferers with similar symptoms are considered by some members of their community to have fright illness, while other members of the community offer different diagnoses. In attempts to interpret such a complex illness profile researchers may focus on one of the local diagnoses and ignore the others. For example, if segments of the same population have different criteria for defining illnesses, which criteria are appropriate for deciding to include or exclude a case? This problem can clearly be seen in the research of Rubel et al. on susto. We had gone to interview Rogelio on the recommendation of his first cousin, a woman who labeled him “asustado”. On arriving at his house, his lack of well-being was immediately apparent. During that first interview, he claimed his condition was due to mu&a-a choleric but repressed anger. When we later encountered the cousin, she asked what Rogelio had said. When told “muina” she burst into paroxysms of laughter. Finally, noting the ethnographer’s chagrin, she explained between gasps, “the men here are so
381
382
CHARLFX
funny! Because they think it unmanly to suffer from susto, they prefer to call their problem muina” [4, p. 501.
That Rubel et al. elected to include such cases in their sample of susto sufferers suggests acceptance of the underlying assumption that in Zapotec culture something locally unique is going on. and that there is a definable folk illness ‘object’, susto, that can be manifest. counted, and measured, even if it is locally defined as something else. Rubel et a/.‘~ reportage of the difference in cultural perception of illness in the local setting clearly indicates a basic problem of case identification. They decided that a case would be identified on the basis of local opinion, but very often no local consensus is possible, making case identification imprecise and subject to a variety of influences (e.g. status, power, wealth, local credibility, etc.). A significant contribution to the debate over the issue of the fright illnesses as culture-bound syndromes has been Simons and Hughes’s [l] suggestion that these culture-bound illnesses be more precisely defined and classified into a number of illness taxa. This proposal has been a positive means of putting the object of study in better focus by illuminating important differences in the illness phenomenology of the various illness conditions associated with fright. The taxa they suggest differentiate between those fright illnesses where sudden frights are clearly associated with florid symptoms (as in the coprolalia and compulsive mimicry held to be associated with latah) [9], and those illnesses which lack a coherent set of symptoms [I]. Simons and Hughes divide fright illnesses into two distinct taxa. the Startle Matching Taxon. typified by conditions such as latah and imu [IO] with a probable physiological basis, and the fright illness taxon. exemplified by thing in China [6], susto in Latin America [I I-131 1, lanti in the Philippines [l4]. and mogo laya in Papua New Guinea [15], the fright illness in Northwestern Iran [16], and the type reported here. the Yemeni conditionfja’. While there is growing consensus that the Startle Matching Taxon does represent culture-bound psychiatric syndromes with distinct clinical profiles [I, 17, 181, the same does not hold for those illnesses in the fright illness taxon. In the fright illness taxon the major stumbling block is the confused picture of the illness symptomatology. For example. in the Chinese health ideology reported by Kleinman [6]. the fright illness (thing) is frequently associated with acute sickness of common developmental problems in children. In Northwestern Iran Good and Good [16, p. 1521 also report that fright illness is associated with a wide ranging illness symptomatology that includes jaundice, nervousness, fever. heart palpitations. mouth and eye problems, and insanity. In the Hispanic condition susto the descriptions of symptomatology also vary significantly [7]. In some reports susto is associated with a cluster of symptoms that includes disturbed sleep, anxiety, and loss of appetite, lack of interest in personal care. and general signs of distress. However, in one of the first examinations of the epidemiological profile of a fright illness. O’Nell and Selby’s [12] study of susto in two Zapotec villages found that the range of symptoms associated with the condition also in-
F. SWAGMAN
eluded fever, muscular pains, complexion changes, nausea and other stomach or intestinal upsets, vertigo, intense thirst, and rectal bleeding. In a later study, Rubel. O’Nell and Ardon conclude that: asustado’s suffered more disease signs and symptoms than their matched controls and these vvere more impairing and life-threatening. On the other hand. no single condition or system involvement differentiated between the two groups with one interesting exception. That exception referred to the aggregation of symptoms-lack of appetite. tiredness. loss of weight, loss of strength, and lack of motivation-that were reported so often in association with diverse serious health problems. This aggregate was the only marker of organic difficulties that unambiguously distinguished the asustados from those patients without susto. Thus. in a universe of sick individuals. asustados were significantly more afflicted than others by a cluster of symptoms representing diffuse systematic attacks on the organism (4. pp. 1141151. Rubel er al. opine that in three communities in Oaxaca “the susto illness is formed by sociocultural understandings which help mold individual experience as modified by the effects of those organic diseases endemic to a population. Together, these forces construct a mala& (emphasis added) which is meaningful to members of these societies” [l9]. The lack of clearly defined symptomology is the point that is most often used to challenge the position that a single syndrome is manifested: that a culturally specific illness syndrome with some clinically definable physical components is generated. However, given the great variability in symptoms in the fright illness taxon. there is no coherent ‘etic’ or standardized set of symptoms against which specific cases may be matched. Thus, in this class of folk illness, there is no objective way of determining a case; an illness ‘object’ that is not clearly definable is subject to different perspectives. interpretations. and assessments by individuals or groups. This inherent lack of precision in diagnosing a case presents a fundamental problem for epidemiological assessments and shows that such folk categories as the fright illnesses do not form syndromes based on a consistent set of symptoms [20]. Fright illnesses as expianutor!~ models An alternative approach to the ‘culture-bound syndrome’ model of folk illness. which avoids the problem of trying to match variable diagnoses with equally variable sets of symptoms. is one that focuses on the ideational level. In all the reported disorders classified under the fright illness taxon, fright is perceived as a precipitating event. that is. fright is a part of the folk etiology of the illness. However, in most examples of the fright illness taxon the actual association between a specific fright and the manifestation of illness is neither clear nor direct. Most often there is a process of introspection and/or local discussion after the manifestation of symptoms in which the illness is attributed to an antecedent event or fright [8]. Kleinman and Good and Good, advocates of a meaning centered’ approach to the analysis of folk illnesses, consider the phenomenon in Iran to be the product of local medical discourse; a folk illness is in essence a cultural explanation that can be coupled to a multiphcity of underlying clinical dis-
Yemeni fright illness orders and symptomatology. As an illness category in this formulation, fright is a component of a culturally constructed illness mode1 that is etiological and explanatory in nature; it is principally a manifestation of the cultural process of assigning meaning to disturbing illness processes. From an ideational perspective questions about the nature and distribution of fright illness in society may be addressed while leaving aside the vexing problem of confounded case identification. Instead, ascertaining which segments of the population suffers from a specific folk illness, it is fundamentally a problem of mapping the presence of a particular form of medical knowledge in a population; an epidemiology of meaning rather than an epidemiology of ‘disease’. Thus, the sociocultural profile of fright illness may be at least partially explained through analysis of factors that affect the distribution of medical knowledge. Because such processes are primarily ideational, they are influenced by a wide variety of social and historical forces. However, most medical anthropological studies of folk illness categories adopt a synchronic approach with the underlying assumption that ‘traditional’ medical beliefs are enduring and stable. In most analyses of these phenomenon there is little evidence of awareness that the communities under investigation are themselves undergoing a continual process of change, and that the forces affecting change may be of additional explanatory value in understanding the particular sociocultural profile of the local health situation. However, in a significant departure from the assumption of stability and cultural homogeneity in traditional societies, Jilek and Jilek-Aall [2l] have shown that both pattern and meaning of folk illnesses are subject to change within culture. As a further example of analysis that recognizes the importance of culture change on the social profile of folk illness let us review some preliminary. but suggestive. data from highland Yemen. FRIGHT AND ILLNESS IN YEMEN
Background The traditional Yemeni health ideology is an amalgam of pre-Islamic folk beliefs, Prophetic medicine Arabian (if -rib/7 an-nabawi). and the classical medicine (it-ribh al-‘arabi) derived from the ancient Hellinistic tradition. Arabian medicine incorporates notions of homeostasis and humoral balance in a dialectical relationship between a macrocosm consisting of the basic elements earth. air. fire, and water, and associated properties of heat. cold, wetness, and dryness, and an organic microcosm based on the same elements. The human body is composed of four basic fluids (humors) which have their own correlates in the macrocosm: black bile (suda), yellow bile (sufra), phlegm (balghm) and blood (dam) [22]. However. this classical system is only a part of the Yemen medical ideology. While most popular explanations of illnesses mention the humors and express the notion that balances may be upset, very few folk explanations actually indicate recognition of the intricate theoretical relationships between the elements in the classical system. As a medical belief system. the Prophetic medicine, tibb an-nabawi. is limited to a few public health
383
recommendations. The Prophetic medicine is, however, closely linked to beliefs confirmed in Islamic doctrine about the existence of the soul (nafs) and supernatural beings such as jinn, zar, and other spirits (rub, arwah) that have the power to impact states of health. From the pre-Islamic medical ideology a few beliefs continue to be strongly held. The pernicious effects of envy and jealousy manifest in the Evil Eye (‘iyn) are considered to be major causes of illness, as are the powers of sorcerers (suhar) to manipulate the spiritual beings through ancient rituals described in books such as Shamsh al-Mu’arrif al-Kubri, and Mandal as-Sulayman (Solomon’s Magic). The causal effect of a sudden fright or shock is also an important persisting element of these ancient belief systems. Finally, in addition to the Arabian medicine, the Prophetic traditions, and the indigenous beliefs, there is an increasing volume of medical knowledge associated with Western cosmopolitan health care. After centuries of virtual isolation. the revolution of 1962 precipitated tremendous cultural change in Yemen. Through a variety of channels including wide-scale emigration, development of mass media, education, and health care development programs, opportunities for segments of the people to absorb additional forms of medical knowledge have dramatically increased, further adding to an already pluralistic medical belief system. Until very recently the dominant health ideologies in Yemen were derived from ancient forms of knowledge. Prior to the revolution. and the end of the centuries of isolationism, medical knowledge was either in the form of the classical Arabian medicine, the Prophetic medicine, or the local indigenous beliefs. Within this defined set of ‘traditional’ beliefs, fright was a commonly accepted component of local explanatory models. Since the revolution. however, cosmopolitan medical knowledge has diffused in the population further expanding the medical pluralism and offering additional alternatives to the prior forms of medical knowledge. Ideas such as ‘germs’. ‘nerves’. ‘hysteria’, ‘dirty water’, ‘anxiety’, ‘poor nutrition’ and ‘weak blood’. are contemporary reasons commonly given to account for general, clinically vague health problems which were formerly attributed to such folk categories as fright. Thus. the historical distribution of medical knowledge is an important variable to take into account in the analysis of folk illnesses. The phenomenology qffja’ The word fija’ is derived from the Arabic verbal root faja’a; the meanings of the words derived from this root are all associated with calamity, disaster, and distress. In the Yemeni vernacular fijaC refers both to a sudden fright or startle. and the illness state associated with a sudden fright. In the popular health ideology, the mechanics of how the fright causes illness are not well articulated; most people are merely able to point to the association between the two. The few informants who offered more detailed explanations suggest that a sudden fright can cause a general imbalance within the body, an imbalance that must be corrected by a counter shock or illness will result. Another interpretation is that the fright causes the displacement of the soul, (nafs) which, if not shocked back into position, will result in illness. A
CHARLES F. SWAGMAN
384 sense
gained
of how fright and illness are linked can be best through a review of some case examples.
Fija’ as a folk
illness
Ca.ce 1. In the southern highlands a 30-year-old woman witnessed her husband’s Toyota Landcruiser begin to roll towards a sheer drop with her son in the back seat. The vehicle stopped just before reaching the edge, but the woman was so frightened that she became weak and dizzy. She rested for a while and seemed to recover from the shock but later that evening she had very disturbed sleep. The next day she began to complain of dizziness and dropped plates and bowls while preparing the noonday meal. She began to complain that she was suffering from fija’ and after some discussion among her family, it was decided that her fright had brought on her illness. Later that evening she was suddenly grabbed from behind by her husband, and while she was held down. her brother applied a glowing hot iron to the back of her neck. After she stopped sobbing and wailing and began to recover from the second, counterbalancing shock. she went to bed and rested. The next day she had to contend with a severe bum, but was no longer suffering from the symptoms of fijac,
In this case the fija’ was directly associated with her subsequent changes in behavior; the illness state followed soon after actually experiencing a profound fright. According to the belief system, she was seen to suffer from an imbalance of her spirit or essence (nafs. rub) which generated her illness symptoms. This type of experience is probably the kind of ‘kernel of truth’ which generated and perpetuates the fright theory here as elsewhere. However, very few of the cases of fija’ follow this ideal pattern: a rapid manifestation of a limited set of shock induced anxiety symptoms and quick recovery after the counterbalancing shock. By far, most of the cases are retrospectively diagnosed after a considerable time period has lapsed. More typical examples of fija’ can be seen in a review of other case histories taken from the western central highlands region of Yemen. Ccrsr -7. This case mvolved a 25year-old woman who had been married for IO years. She had been pregnant three times; two male children were alive and one male child had died in infancy. She had delivered her last child 5 months prior to her visit to the hospital. Her father was a mason and her husband drove a tractor and had worked in Saudi Arabia off and on over the past IO years. Nevertheless. she described herself as a poor person (miskina). Her husband had been working in Saudi Arabia for just over a year and returned to Yemen because of her complaints of pain. The woman had been suffering abdominal pain and weakness with occasional vomiting for about one year. Clinically. she was diagnosed as suffering from gastritis. She, herself, described her condition as “a pain in the mouth of the stomach. that IS, the y&b” r23]. She attributed the cause of the illness to a fright (fija’). that she had experienced upon hearing of a young healthy man in the neighborhood who suddenly died after chewmg qat. The fright happened just after her husband had departed for Saudi Arabia. Over a year passed before she presented her problem to the doctor. although she had sought local religious treatment and had four amulets (hurt) written to counter the illness (at U.S.S50 each). Cuse _?.A 35year-old wife of a stone mason had complained of suffering weakness, cough, chest pain. and pain in the back for just over a year. She occasionally coughed blood. She had also recently given birth to another baby at the time of the onset of the symptoms. She described her illness as
an mabilny to do her work. especially fetching water and hauling heavy loads. She was tested and found negative for TB. and was diagnosed as suffering from chronic bronchitis. She attributed her illness to a tija’ from a car accident that occurred behind their house just after she had delivered her baby. when she was in a very weak state. One month before the visit to the clinic (almost a year after the onset of the symptoms). she had been taken to a neighbor who burnt her with red hot irons on the back of the neck and on the forehead. but it was not effective. Her brother-in-law was bringing his wife to the hospital so she had the opportunity and decided to come along and be seen by a medical doctor.
Case 4. A 27-year-old woman. a member of one of the lower classes in Yemeni society. came to the clinic with her female cousin. Her husband was an occasional potato broker. general laborer, and had worked in Saudi Arabia. but was now back in Yemen, again looking for work. Her father was a qat seller. She described her problem as a general weakness accompanied by chronic pain, especially in the liver, back. chest, and abdomen. She also had a chronic cough and fever. She was clinically diagnosed as suffering from pneumonia and was infected with intestinal parasites. She attributed the cause of the illness to a fija’ suffered when her brother was hit by a car some 6 years previous. though the brother was uninjured. She had been burned on the back of the neck after the first manifestations of the symptoms years earlier, but had no other treatments. She said she had been weak ever since the fijac, and that the onset of this manifestation of the problem was triggered by her delivery of a baby about 10 days before. In side notes, the medical doctor reported that the woman was concerned that her clinical illnesses might interfere with her ability to get pregnant again, and that she had stopped taking her medications because the women of her village told her the pills she was taking would prevent her from getting pregnant. Case I The case involved a 27-year-old married woman. Her husband, a mechanic. had been working in Saudi Arabia for the past year and a half. She came to the hospital suffering from difficult breathing and weakness, feeling “that her knees could not support her any more”. She also reported that “sometimes her heart would race faster and faster until she felt as if something had opened in her back”. She complained that the symptoms had been a problem for over 4 years. She was clinically diagnosed as suffering from gastritis with retrosternal pain. She attributed the onset of the problem to the death of her brother 4 years prior and the resulting fijai, In describing the fright and resulting condition she said “ruhi faira”. my spirit (or soul) fell down. She had been taken to a number of doctors throughout Yemen. Many people had advised that she be burned, but her father refused because of the pain it would cause her. Case 6. The case involved a 30-year-old woman who had yet to give birth to a child. Her husband was a migrant worker in Saudi Arabia. He has been working since before their marriage some I I years ago. HIS pattern was typical of most Yemeni migrant workers, staying away for 2 years and then coming home for 612 months before returning to find more work. She was uncertain of who was to blame for the primary sterility. She reported that she thought it might be a problem with her husband because he refused to take another wife and rumors had it that he was examined in Saudi Arabia and found to be sterile. She came to the hospital complainmg of painful intercourse and weakness. She described the parn she experienced during intercourse as “a fire going through her body, making her so weak that she was about to die”. She attributed the pain to the fact that she had been washing a heavy blanket before they had sex. However, a relative. an old masseuse suggested that the problem was from a fija<. A few weeks before coming to the clinic she was therapeutically burned twice, once on the solar plexus and once on the back. but the pain and weakness had not subsided
Yemeni fright illness These case outlines illustrate how fija’ is associated with wide ranging symptomatology. It includes general weakness, shortness of breath, dizziness, fitful sleep, chronic cough, fever, abdominal, chest and back pain, liver pain, and sexual dysfunction. The clinical diagnoses of these case examples also indicate a range of physical problems including gastritis, chronic bronchitis, pneumonia and intestinal parasites, primary sterility and painful intercourse. While a few symptoms such as general weakness and anxiety appear in several cases, these symptoms are so general that they do not provide enough significant basis for clinically defining a syndrome. Furthermore, the majority of the cases indicate such a considerable and variable time lapse between the reported fright and the onset of the various symptoms that causal connections are at best dubious. Rather than being an example of a culture-bound syndrome, the evidence indicates that fija’ is an ‘explanatory model’ which incorporates a wide range of illness symptoms [6]. Caution should be exercised in drawing broad generalizations on the basis of a few case studies, but the Yemeni data reveals significant similarities between fijac and other examples of the fright illness taxon. The phenomenology of fija’ involves a fright which creates an imbalance. This must be restored, often by a second shock. Similarly a common treatment for susto in Mexico also involves administration of a second, balancing shock such as a spray of cold water in the patient’s face [13] and Good and Good [16] report the use of burning as a counteracting treatment for fright illness in western Iran. The cases from Yemen also illustrates the widespread notion that there can be a significant time period between the alleged frightening event and the onset of the particular illness episode. Similar delays between fright and onset of symptoms are found in susto [I, 4, p. 1191. Thus, the similarities in illness ideology and the range of physical treatments suggests that a comparison of examples within the fright illness taxon may be useful. The social distribution of jright illness
A review of the various examples from the fright illness taxon indicates that fright as an etiological illness category tends to cluster among women, children, and lower class men [24]. In their earlier research O’Nell and Selby reported a significantly higher incidence of susto among women, and in western Iran Good and Good [16, p. 1.541 also indicate an asymmetrical distribution of the illness; women and children tend to be overrepresented. Similarly, Morsy [25,26] indicates that in Egypt both the fright illness tarba with its variable symptomology and as well as the folk illness ‘uzr, in which fright is presumed to have etiological significance, women, children, and lower class men are more likely to manifest the disorder. My data from the highlands of Yemen seems to conform to the same pattern. In addition to the case studies presented above, evidence drawn from the observations of health care development workers indicates that fijac is one of the most common etiological illness categories among Yemeni women. In their preliminary study of mother and child health in the rural mountains of western
385
Yemen, Johnson et al. [27] report that fija’ is one of the principal causes of illness offered by women to explain a range of maladies, and in their study of malnourished children Beaty and van Dijk [28] indicate that fright ranks just behind the ubiquitous ‘evil eye’ as a ‘supernatural’ explanation given by women to account for nonspecific illnesses. By contrast, in my interviews with 61 randomly sampled male heads of households in four villages, fijac was given as a cause of illness in only one case out of 439 reported illness episodes [29]. Fija’ was indicated as the cause of a case of qalaq (severe anxiety) experienced by a woman after the earthquake of 1982. The only case I recorded involving a male was a boy in his early teens who had tripped and had the wind knocked out of him; as he recovered his breath, his group of playmates again wrestled him to the ground and put a burning match to the back of his neck as a preventative measure before he could develop symptoms. In this survey, when asked to speculate on the causes of common illnesses, most tribesmen offered etiologies closely aligned with the causal factors articulated in the classical Arabian medicine and with the more cosmopolitan theories of causation. These data suggest that fija’, like susto, is much more likely to be a diagnosis made by women for conditions suffered by women and children. While the number of case studies is not yet sufficient to support generalized conclusions based on comprehensive hologeistic research, the ethnographic evidence is strong enough to warrant the construction of some tentative explanations for this sociocultural profile. An answer to the question why illness experiences are expressed in the fright illness idiom by one segment of the population and not another may be found by employing the analytical notion of patient explanatory models (EMS) [6, pp. 104-l 181 as evidence of medical knowledge, and by looking at social, and cultural factors which may affect the distribution of medical knowledge in society. In seeking an explanation for the relative absence of fright illness among men, a good place to start is the cultural value systems [30]. Societies with an apparent concentration of fright illnesses among women and children also maintain a value system that emphasizes a ‘macho’ type of male social role in which the male. as the protector/provider of the household. should be strong, powerful, and dominant. This is clearly evident in the comments of the Zapotec woman mentioned above. In Yemen society social status is carefully defined and maintained. At the upper end of the ascribed status ‘hierarchy’ are the religious elites (sa_vyid-sand qadhi-s) while at the lower ends of the hierarchy are the nontribal ‘Arabs’ (Bani Khums, nuqqas) and the descendants of nonArab groups such as former state servants (akhdam). However, the core of Yemen society is composed of the tribesmen (qabili-s), descendants of the noble South Arabian tribes [31-331. In tribal Yemen, the ideal male role is embodied in the tribal ethos (often reported as qabayla). In her detailed analysis of qabayla Adra observes that “the ideal qabili (tribesman) is courageous, generous, recognizes his obligations toward proteges, is faithful to his word, and has a strong sense of justice. The qabili is also strong,
CHARLES F. SWAGMAN
386
hardworking, and a man” [34]. Consistent with my findings on fright and illness, she also reports that: The importance of courage in tribal identity. is expressed also in attitudes towards fearfulness, which is considered a dangerous state to be avoided at all cost. Fright is considered to lead to a pathological state called fija’ (torment, misery). A person who has been frightened as a result of a fall, from witnessing an accident or near accident, or even from an imagined danger becomes agitated and distracted and may complain of heart palpitations or trembling hands, symptoms of fija’. These symptoms are taken seriously and treated by touching a predetermined part of the body (usually the back of the neck) with a burning brand. Thus, fearfulness is. in tribal world view, physical. It is not something that can be avoided or overcome by conscious control. Only one’s physical stamina determines whether or not one can be frightened easily, and measures are taken to protect the weakhearted from exposure to frightening situations. Some women will not walk along between villages at night. and infants are not taken outdoors at night because it 1s assumed that they will be frightened (34, pp. 1461471. The emphasis
on the ideal
of strength
and
courage
in
Yemen tribal society may provide part of the answer to the question why fija’ is rarely reported by men as an illness category. To admit to suffering from fright is to admit to a weakness that challenges the very essence of being a tribesman. If a man is not perceived of as courageous and strong and able to protect his family and property, his sense of self, his social status as a man, and by extension, his identity as a tribal warrior is at risk [35]. Therefore, men may elect to cast their illness experiences in alternative cultural idioms that do not imply any basic character weakness. Yemeni women, on the other hand, are generally regarded as weak and vulnerable to external threats. Falling victim to illness precipitated by fright is consistent with the cultural definitions of female identity. Given the complexities of human behavior, very often multiple factors are operating at any one time to influence health related behavior. Thus, explanations can be postulated at multiple levels without necessarily contradicting or cancelling the other. A second. and complementary explanation may be found in examining how cultural attitudes and values affect the availability and distribution of form of medical knowledge. especially in a changing cultural environment. In Yemen tribal society most social relations are conceived of in terms of honor (sharuf, ‘and. H@) and shame (‘u~b) (34, 36-381. Of primary importance in retaining social standing is the maintenance of tribal and family honor. As in most Arab culture. tribal and family honor is symbolized most visibly in the virtue of the women, and social conventlons are elaborated to insure its preservation [39.40]. In rural Yemen these conventions include such behaviors as veiling and segregation by sex in any public or semi-public forum. Additionally, women’s social and physical space is limited to that in which honor can be defended, that is, the household and local community, and tribal land. In opposition to these protected spaces are public places where honor is seen as highly vulnerable, especially the market (suq). Given that most educational, health. and government facilities have been located in or around major commercial centers, Yemeni tribal
women have had very limited access to these sources of medical knowledge. Following the 1962 overthrow of the thousandyear Zaydi Immamate, Yemen’s end to centuries of isolationism resulted in new opportunities for socioeconomic and cultural change. Access to new forms of medical knowledge through channels such as formal education and printed media, military service. emigration to neighboring oil producing countries. as well as the direct exposure to cosmopolitan health care facilities that these opportunies afforded. was concentrated among males from the higher social status categories. As a consequence of these socioeconomic and cultural changes Yemeni women and young children (and lower class men) have limited exposure to alternative (i.e. cosmopolitan) health care ideologies. Yemeni women, who are very restricted in their social space and whose channels for information are circumscribed tend to be more traditional and conservative in the range of cultural beliefs offered to explain illness (411. In contrast to the ‘modern’ explanatory models offered by Yemen men, the women interviewed offered etiologies more closely associated with pre-Islamic, supernatural, and specifically Yemeni folk beliefs: their range of ideas about health were more narrowly confined to those held by and transmitted within the members of their immediate social world. Thus. differences in social relations and potential life experiences have resulted in differences in the general ideologies held by Yemeni men and women. Fija’ is one of the central etiological illness categories in the indigenous health care belief system. It may also be argued that women (and lower class men) associate fijaL with illness more often than men because of the absence of competing alternative explanatory models. As fija’ is one of the most prominent explanations that can bc attributed to a wide range of illness states, it is reasonable to hypothesize that the highest incidence would be found among those members of Yemen society whose medical explanatory models are most limited to indigenous forms of knowledge. CONCLUSION
The work of Simons and the contributions of the more ‘meaning centered’ analysts has helped to reshape much of the thinking about the fright illness taxon. When no longer considered as specific syndromes or disease objects. these nebulous folk illnesses become amenable to different approaches which may better account for their particular sociocultural profiles. People with illness symptoms, through negotiation with a healer. rheir family members, or through process of self-reflection and rationalization within the medical behef systems. settle upon satisfactory explanations that attribute illness experiences to specific causes: the result is a complex illness profile in which a variety of clinically defined states may be attributed to a single cause such as fright. The social distribution of specific folk illnesses like fijac may be reinterpreted to be a reflection both of the distribution of medical knowledge in culture and of cultural values. In sum. it is suggested that explanations for the patternmg of folk illnesses may
Yemeni be improved by taking into account the social relations that affect the distribution of medical knowledge in addition to the customary analysis of possible factors (e.g. psychosocial stress) that might contribute to clinically definable illness states that are cast in local folk-illness idioms. am particularly indebted to Fatima Zuhra Woehlers-Olsen Kaserat, M.D., M.P.H. for her cooperation in administering the outpatient questionnaires from which the case examples were drawn. The research was conducted between 1982 and 1984 while I was the medical anthropologist for the Dhamar Governorate Health Services Programme in the Yemen Arab Republic; however. the views expressed in this paper are solely the author’s, I would also like to thank Dr John G. Kennedy for his many helpful comments in the development of this paper.
fright
18. Simons R. A feasible and timely enterprise:
,9.
20.
Acknon~ledgemenrs--I
21.
REFERENCES
22.
Simons R. and Hughes C. (Eds) The Culture-Bound
5. 6. 7. 8. 9.
IO.
11. 12.
13. 14.
15. 16.
17.
Syndromes. Reidel, Dordrecht, 1985. Hahn R. A. Culture-bound syndromes unbound. Sot. Sci. Med. 21, 165-171. 1985. Klein J. Susto: the anthropological study of diseases of adaptation. Sot. Sci. Med. 12, 23-28, 1978. Rubel A. J.. O’Nell C. and Collado-Ardon R. Susfo: A Folk Illness. University of California Press, Berkeley, Calif., 1984. Bolton R. Susro: hostility and hypoglycemia. Ethnology 20, 261-276, 1981. Kleinman A. Patients and Healers in the Context of Culture. Umversity of California Press, Berkeley, Calif., 1981. Trotter T. Susto: the context of community morbidity patterns. Elhnology 21, 215-226, 1982. Simons R. C. Introduction to the fright illness taxon. In The Culture-Bound Svndromes (Edited bv Simons R. and Hughes C.). Reidel. Dordrecht, 1985: Murphy H. B. M. Notes for a theory on latah. In Culture-Bound Syndromes, Erhnopsychiatry, and Alternate Therapies (Edited by Lebra W.). The University Press of Hawaii. Honolulu, Hawaii, 1976. Ohnuki-Tierney E. Shamans and Imu: among two Ainu groups-towards a cross-cultural model - of interpretation. In The Culture-Bound Svndromes (Edited by Simons R. and Hughes C.). Reidel, Dordrecht, 1985.. O’Nell C. W. An investigation of reported ‘fright’ as a factor in the etiology of susto, ‘magical fright.’ Efhos 3, 41-63. 1975. O’Nell C. W. and Selby H. A. Sex differences in the incidence of susto in two Zapotec pueblos: an analysis of the relationship between sex role expectations and folk illness. Ethnology 7, 95-105, 1968. Rubel A. J. The epidemiology of a folk illness: Susro in hispamc America. Efhnology* 3, 268-283, 1964. Hart D. V. Lanti. illness by fright among Bisayan Filipinos. In The Culrure-Bound Syndromes (Edited by Simons R. and Hughes C.). Reidel, Dordrecht. 1985. Frankel S. Mogo Laya. A New Guinea fright illness. In The Culrure-Bound Svndromes (Edited by Simons R. and Hughes C.). Reidel, Dordrecht, 1985.. Good B. and Good M. J. D. Toward a meaning centred analysis of popular illness categories: fright illness and heart distress in Iran. In Cultural Conceptions of Mental Healrh and Therapy (Edited by Marsella A. 1. and White G. M.). Reidel. Dordrecht, 1982. Prince R. and Tcheng-Laroche F. Culture-bound syndromes and international disease classifications. Culr. Med. Psychiat. II, 3. 1987.
illness
23.
24. 25.
26.
27.
28.
29.
30.
387
commentary on “culture-bound syndromes and international disease classifications” by Raymond Prince and Francoise Tchgeng Larouch. Cult. Med. Psychiat. 11, 21. 1987. Rubel A. J. er al. The folk illness called Susfo. In The Culture-Bound Syndromes (Edited by Simons R. and Hughes C.). Reidel, Dordrecht, 1985. Stedman’s Medical Dictionary. 24th edn. Williams & Wilkins, Baltimore. Md, 1982. defines a syndrome as “the aggregate of signs and symptoms associated with any morbid process, and constituting together the picture of the disease.” Additionally. DSM III-R defines a syndrome as “a group of symptoms that occur together and that constitute a recognizable condition,” p. 405. Central to each definition is the idea that a syndrome is identified on the basis of a recognizable set of symptoms. Due to the wide variation in symptomatologies the examples from the fright illness taxon do not meet the basic requirements to be classed as syndromes. Jilek W. G. and Jilek-Aall L. The metamorphosis of ‘culture-bound’ syndromes. Sot. Sci. Med. 21, 2055210. 1985. Browne E. G. Arabian Medicine. The University Press. Cambridge. 192 1. In Yemeni dialect the word qalb literally means heart, but in general terms, the word also simply means center. For example. the center of a motor is the qalb, as is the main point of an argument. It is quite similar in usage to the English terms for heart. Morsy S. Sex roles, power and illness in an Egyptian village. Am. Efhnol. 5, 137-150. 1978. Morsy [24] argues that class is an important factor in the incidence of the Egyptian condition ‘uzr. and that women are particularly susceptible. Good and Good [16, p. 1541 present a table that indicates a loading of cases of fright illness among women and children in Iran. Additionally, the work of Rubel [13] and O’Nell and Selby (121 also indicate this. Morsy S. Gender, power and illness in an Egyptian village. Ph.D. dissertation, Michigan State University, 1978. Johnson C. O’Reilly M. and Soutar D. A baseline health study of three areas in al-Ja’afariya District. Unpublished field report. British Organization for Community Development. Yemen Arab Republic. 1985. Beaty S. and Dijk R. van. Determinants of childhood malnutrition. Unpublished manuscript. Dhamar Rural Health Proiect. Yemen Arab Reoublic. 1987. Structured *interviews were conducted among 25% of the male heads of household in four villages in western Anis in which details of recent family illnesses. folk etiologies. treatment choices and decision making procedures were elicited. To select the sample. a list of all heads of households was provided by the village tax assessor or shaykh and the respondents were selected by use of a random numbers table. All four villages were similar in size. ecological zone. and distance from cosmopolitan health facilities. See Swagman C. F. Health culture and change: health care development in highland Yemen 1988 (unpublished manuscript) for a more detailed discussion of the structure of Yemen health beliefs. The Beaty and van Dijk study was also conducted in Dhamar province and included some of the same villages in Maghrabet al-‘Anib involved m my research. In this article the argument has been to explain why a common illness category is not frequently expressed by men, rather than examining the question from the complementary position of why it is often used by women. In contrast to Boddy’s (1988) work on Sudanese zar, where she accounts for its high prevalence among women through an analysis of the female ‘self’, the susceptibility to fright does not seem to be grounded
388
CHARLES F. ^~WAGMAN
in gender identity. In the vernacular ideology, all people can be subject to fright, and in fact, are. Thus, the emphasis on the negative case, the denial aspect of men, seems to be the more reasonable course of analysis. T. Market Mosque and Mufraj: social 31. Gerholm inequality in a Yemeni town. Stockholm Stud. Sot. Anrhrop. 5, 1917. 32. Stevenson T. Et. Social Change in a Yemeni Highland Town. University of Utah Press, Salt Lake City, Utah, 1985. 33. Swagman C. F. Development and Change in Highland Yemen. University of Utah Press, Salt Lake City, Utah. 1988. the tribal concept in the central 34. Adra N. Qabayla: highlands of the Yemen Arab Republic. Ph.D. dissertation, Temple University, 1982. Sudan: the 35. Boddy J. Spirits and selves in northern cultural therapeutics of possession and trance. Am. Eihnol. 15, 421. 1988.
36. Caton S. Salam Tahiya: greeting from highland Yemen. Am. Ethnol. 13, 29&308, 1986. 37. Dresch P. The position of Shaykhs among the northern tribes of Yemen. Man 19, 31-49, 1984. 38. Dresch P. The significant of the course events take in segmentary systems. Am Erhnol. 13, 309-324, 1986. 39. Dorsky S. Women of ‘Ammn. Universitv of Utah Press. Salt Lake City, Utah, 1986. 40. Makhlouf C. Changing Veils: Women and Modernizarion in Norrh Yemen. Croom Helm. London. 1979. 41. As an example of the notion that women in rural Yemen are, in a sense ‘keepers’ of historically deep beliefs. it has often been noted that the women speak a dialect of Arabic that can be quite localized and relatively uninfluenced by outside dialects. In Jibal Rayma there were a number of linguistic markers, such as the use of kafas a future prefix and the use of kaf as the final consonant in the second person masculine perfect form of verbs.
FIJA’:
FRIGHT
AND
0277-9536189 $3.00 + 0.00 Copyright C 1989 Pergamon Press plc
ILLNESS CHARLES
7446 W. 91st Street,
F.
IN HIGHLAND
YEMEN
SWAGMAN
Los Angeles,
CA 90045. U.S.A.
Abstract-Sudden fright. Sja”. has played an important role in the traditional explanatory models of illness experiences in highland Yemen. Fijac is quite similar to other examples of the fright illness taxon in that it is a folk-illness category that is attributed to a wide variety of underlying conditions. It is argued that given the extremely labile symptomatology, fija’, like other examples of the fright illness taxon, does not constitute a culture-bound psychiatric syndrome. Based on analysis of case studies and preliminary survey data, fijac appears to be much more common among folk etiologies offered by Yemeni women than men. It is suggested that this social profile might be explained by changes in the distribution of medical knowledge in Yemen. With the rapid rate of social change and the increased exposure to cosmopolitan medicine resulting from internal development of cosmopolitan health care and international labor migration, men have supplemented their traditional explanatory models with alternatives drawn from cosmopolitan medicine. Succumbing to illness as a result of fright is contradictory to the male ideal of the courageous tribesman; alternative explanatory models that do not challenge this ideal self predominate. By contrast, the Yemeni value system defines women and children as vulnerable and weak; therefore, being subject to the impact of fright is consistent with youth and the cultural definition of the female self. Kqv w>ords-Middle
East, Yemen,
folk illness, medical anthropology
This paper addresses two basic questions in the analysis of folk illnesses associated with fright: is it still useful to continue to employ the construct ‘culture-bound psychiatric syndrome’ in the analysis of conditions subsumed under the ‘fright illness taxon’? and what factors influence the distribution of such fright illnesses in a society? In participating in the debate I will present some preliminary data from highland Yemen that supports the growing body of opinion that many of the fright illnesses should no longer be considered as culture-bound psychiatric syndromes (11. In this paper it is also suggested that questions about the distribution of fright illnesses in society might best be answered by examining factors that influence the distribution of medical knowledge in society. As a prelude to the discussion it is important to briefly review previous treatments of these problems. Fright and illness: contrasting perspectives
Sudden shock. startle, or fright has been associated with illness in many cultures. While the importance of culture in shaping such folk illnesses is universally recognized, a basic question about the role of culture in the illness process, whether it “causes something locally unique to happen or is it merely the symbol system for elaborating ubiquitous pathological processes,” remains of interest [I, p. xiii]. Among the adherents to what Hahn [2] has labeled the ‘inclusionist’ perspective (who hold that all illness, including the ‘culture-bound syndromes’ are an interaction of cultural, natural, cognitive and psychodynamic factors) there is secondary debate over the status of specific illnesses categories, and whether or not they constitute definable syndromes. With regard to conditions generally included in the fright illness taxon the debate among the ‘inclusionists’ is between two
contrasting perspectives, one which hypothesizes that they constitute unique and clinically definable classes of disorders-culture-bound syndromes [3,4], and the other that interprets them as culturally constructed illness categories that are ascribed to a wide variety of underlying physical conditions [S-7]. While the assertion that many of the conditions included in the fright illness taxon constitute culture-bound syndromes has been effectively challenged on epistemological grounds (81, a valid argument against defining such fright illnesses as ‘syndromes’ may be made on empirical grounds as well. Some of the most significant problems for the analysis of fright illnesses as culture-bound syndromes stem from the apparent contradictions scattered throughout the ethnographic record. For example there is often little local consensus about illness diagnosis and labeling. Ethnographers typically encounter an array of people who are recognized and labeled as ill; sufferers with similar symptoms are considered by some members of their community to have fright illness, while other members of the community offer different diagnoses. In attempts to interpret such a complex illness profile researchers may focus on one of the local diagnoses and ignore the others. For example, if segments of the same population have different criteria for defining illnesses, which criteria are appropriate for deciding to include or exclude a case? This problem can clearly be seen in the research of Rubel et al. on susto. We had gone to interview Rogelio on the recommendation of his first cousin, a woman who labeled him “asustado”. On arriving at his house, his lack of well-being was immediately apparent. During that first interview, he claimed his condition was due to mu&a-a choleric but repressed anger. When we later encountered the cousin, she asked what Rogelio had said. When told “muina” she burst into paroxysms of laughter. Finally, noting the ethnographer’s chagrin, she explained between gasps, “the men here are so
381
382
CHARLFX
funny! Because they think it unmanly to suffer from susto, they prefer to call their problem muina” [4, p. 501.
That Rubel et al. elected to include such cases in their sample of susto sufferers suggests acceptance of the underlying assumption that in Zapotec culture something locally unique is going on. and that there is a definable folk illness ‘object’, susto, that can be manifest. counted, and measured, even if it is locally defined as something else. Rubel et a/.‘~ reportage of the difference in cultural perception of illness in the local setting clearly indicates a basic problem of case identification. They decided that a case would be identified on the basis of local opinion, but very often no local consensus is possible, making case identification imprecise and subject to a variety of influences (e.g. status, power, wealth, local credibility, etc.). A significant contribution to the debate over the issue of the fright illnesses as culture-bound syndromes has been Simons and Hughes’s [l] suggestion that these culture-bound illnesses be more precisely defined and classified into a number of illness taxa. This proposal has been a positive means of putting the object of study in better focus by illuminating important differences in the illness phenomenology of the various illness conditions associated with fright. The taxa they suggest differentiate between those fright illnesses where sudden frights are clearly associated with florid symptoms (as in the coprolalia and compulsive mimicry held to be associated with latah) [9], and those illnesses which lack a coherent set of symptoms [I]. Simons and Hughes divide fright illnesses into two distinct taxa. the Startle Matching Taxon. typified by conditions such as latah and imu [IO] with a probable physiological basis, and the fright illness taxon. exemplified by thing in China [6], susto in Latin America [I I-131 1, lanti in the Philippines [l4]. and mogo laya in Papua New Guinea [15], the fright illness in Northwestern Iran [16], and the type reported here. the Yemeni conditionfja’. While there is growing consensus that the Startle Matching Taxon does represent culture-bound psychiatric syndromes with distinct clinical profiles [I, 17, 181, the same does not hold for those illnesses in the fright illness taxon. In the fright illness taxon the major stumbling block is the confused picture of the illness symptomatology. For example. in the Chinese health ideology reported by Kleinman [6]. the fright illness (thing) is frequently associated with acute sickness of common developmental problems in children. In Northwestern Iran Good and Good [16, p. 1521 also report that fright illness is associated with a wide ranging illness symptomatology that includes jaundice, nervousness, fever. heart palpitations. mouth and eye problems, and insanity. In the Hispanic condition susto the descriptions of symptomatology also vary significantly [7]. In some reports susto is associated with a cluster of symptoms that includes disturbed sleep, anxiety, and loss of appetite, lack of interest in personal care. and general signs of distress. However, in one of the first examinations of the epidemiological profile of a fright illness. O’Nell and Selby’s [12] study of susto in two Zapotec villages found that the range of symptoms associated with the condition also in-
F. SWAGMAN
eluded fever, muscular pains, complexion changes, nausea and other stomach or intestinal upsets, vertigo, intense thirst, and rectal bleeding. In a later study, Rubel. O’Nell and Ardon conclude that: asustado’s suffered more disease signs and symptoms than their matched controls and these vvere more impairing and life-threatening. On the other hand. no single condition or system involvement differentiated between the two groups with one interesting exception. That exception referred to the aggregation of symptoms-lack of appetite. tiredness. loss of weight, loss of strength, and lack of motivation-that were reported so often in association with diverse serious health problems. This aggregate was the only marker of organic difficulties that unambiguously distinguished the asustados from those patients without susto. Thus. in a universe of sick individuals. asustados were significantly more afflicted than others by a cluster of symptoms representing diffuse systematic attacks on the organism (4. pp. 1141151. Rubel er al. opine that in three communities in Oaxaca “the susto illness is formed by sociocultural understandings which help mold individual experience as modified by the effects of those organic diseases endemic to a population. Together, these forces construct a mala& (emphasis added) which is meaningful to members of these societies” [l9]. The lack of clearly defined symptomology is the point that is most often used to challenge the position that a single syndrome is manifested: that a culturally specific illness syndrome with some clinically definable physical components is generated. However, given the great variability in symptoms in the fright illness taxon. there is no coherent ‘etic’ or standardized set of symptoms against which specific cases may be matched. Thus, in this class of folk illness, there is no objective way of determining a case; an illness ‘object’ that is not clearly definable is subject to different perspectives. interpretations. and assessments by individuals or groups. This inherent lack of precision in diagnosing a case presents a fundamental problem for epidemiological assessments and shows that such folk categories as the fright illnesses do not form syndromes based on a consistent set of symptoms [20]. Fright illnesses as expianutor!~ models An alternative approach to the ‘culture-bound syndrome’ model of folk illness. which avoids the problem of trying to match variable diagnoses with equally variable sets of symptoms. is one that focuses on the ideational level. In all the reported disorders classified under the fright illness taxon, fright is perceived as a precipitating event. that is. fright is a part of the folk etiology of the illness. However, in most examples of the fright illness taxon the actual association between a specific fright and the manifestation of illness is neither clear nor direct. Most often there is a process of introspection and/or local discussion after the manifestation of symptoms in which the illness is attributed to an antecedent event or fright [8]. Kleinman and Good and Good, advocates of a meaning centered’ approach to the analysis of folk illnesses, consider the phenomenon in Iran to be the product of local medical discourse; a folk illness is in essence a cultural explanation that can be coupled to a multiphcity of underlying clinical dis-
Yemeni fright illness orders and symptomatology. As an illness category in this formulation, fright is a component of a culturally constructed illness mode1 that is etiological and explanatory in nature; it is principally a manifestation of the cultural process of assigning meaning to disturbing illness processes. From an ideational perspective questions about the nature and distribution of fright illness in society may be addressed while leaving aside the vexing problem of confounded case identification. Instead, ascertaining which segments of the population suffers from a specific folk illness, it is fundamentally a problem of mapping the presence of a particular form of medical knowledge in a population; an epidemiology of meaning rather than an epidemiology of ‘disease’. Thus, the sociocultural profile of fright illness may be at least partially explained through analysis of factors that affect the distribution of medical knowledge. Because such processes are primarily ideational, they are influenced by a wide variety of social and historical forces. However, most medical anthropological studies of folk illness categories adopt a synchronic approach with the underlying assumption that ‘traditional’ medical beliefs are enduring and stable. In most analyses of these phenomenon there is little evidence of awareness that the communities under investigation are themselves undergoing a continual process of change, and that the forces affecting change may be of additional explanatory value in understanding the particular sociocultural profile of the local health situation. However, in a significant departure from the assumption of stability and cultural homogeneity in traditional societies, Jilek and Jilek-Aall [2l] have shown that both pattern and meaning of folk illnesses are subject to change within culture. As a further example of analysis that recognizes the importance of culture change on the social profile of folk illness let us review some preliminary. but suggestive. data from highland Yemen. FRIGHT AND ILLNESS IN YEMEN
Background The traditional Yemeni health ideology is an amalgam of pre-Islamic folk beliefs, Prophetic medicine Arabian (if -rib/7 an-nabawi). and the classical medicine (it-ribh al-‘arabi) derived from the ancient Hellinistic tradition. Arabian medicine incorporates notions of homeostasis and humoral balance in a dialectical relationship between a macrocosm consisting of the basic elements earth. air. fire, and water, and associated properties of heat. cold, wetness, and dryness, and an organic microcosm based on the same elements. The human body is composed of four basic fluids (humors) which have their own correlates in the macrocosm: black bile (suda), yellow bile (sufra), phlegm (balghm) and blood (dam) [22]. However. this classical system is only a part of the Yemen medical ideology. While most popular explanations of illnesses mention the humors and express the notion that balances may be upset, very few folk explanations actually indicate recognition of the intricate theoretical relationships between the elements in the classical system. As a medical belief system. the Prophetic medicine, tibb an-nabawi. is limited to a few public health
383
recommendations. The Prophetic medicine is, however, closely linked to beliefs confirmed in Islamic doctrine about the existence of the soul (nafs) and supernatural beings such as jinn, zar, and other spirits (rub, arwah) that have the power to impact states of health. From the pre-Islamic medical ideology a few beliefs continue to be strongly held. The pernicious effects of envy and jealousy manifest in the Evil Eye (‘iyn) are considered to be major causes of illness, as are the powers of sorcerers (suhar) to manipulate the spiritual beings through ancient rituals described in books such as Shamsh al-Mu’arrif al-Kubri, and Mandal as-Sulayman (Solomon’s Magic). The causal effect of a sudden fright or shock is also an important persisting element of these ancient belief systems. Finally, in addition to the Arabian medicine, the Prophetic traditions, and the indigenous beliefs, there is an increasing volume of medical knowledge associated with Western cosmopolitan health care. After centuries of virtual isolation. the revolution of 1962 precipitated tremendous cultural change in Yemen. Through a variety of channels including wide-scale emigration, development of mass media, education, and health care development programs, opportunities for segments of the people to absorb additional forms of medical knowledge have dramatically increased, further adding to an already pluralistic medical belief system. Until very recently the dominant health ideologies in Yemen were derived from ancient forms of knowledge. Prior to the revolution. and the end of the centuries of isolationism, medical knowledge was either in the form of the classical Arabian medicine, the Prophetic medicine, or the local indigenous beliefs. Within this defined set of ‘traditional’ beliefs, fright was a commonly accepted component of local explanatory models. Since the revolution. however, cosmopolitan medical knowledge has diffused in the population further expanding the medical pluralism and offering additional alternatives to the prior forms of medical knowledge. Ideas such as ‘germs’. ‘nerves’. ‘hysteria’, ‘dirty water’, ‘anxiety’, ‘poor nutrition’ and ‘weak blood’. are contemporary reasons commonly given to account for general, clinically vague health problems which were formerly attributed to such folk categories as fright. Thus. the historical distribution of medical knowledge is an important variable to take into account in the analysis of folk illnesses. The phenomenology qffja’ The word fija’ is derived from the Arabic verbal root faja’a; the meanings of the words derived from this root are all associated with calamity, disaster, and distress. In the Yemeni vernacular fijaC refers both to a sudden fright or startle. and the illness state associated with a sudden fright. In the popular health ideology, the mechanics of how the fright causes illness are not well articulated; most people are merely able to point to the association between the two. The few informants who offered more detailed explanations suggest that a sudden fright can cause a general imbalance within the body, an imbalance that must be corrected by a counter shock or illness will result. Another interpretation is that the fright causes the displacement of the soul, (nafs) which, if not shocked back into position, will result in illness. A
CHARLES F. SWAGMAN
384 sense
gained
of how fright and illness are linked can be best through a review of some case examples.
Fija’ as a folk
illness
Ca.ce 1. In the southern highlands a 30-year-old woman witnessed her husband’s Toyota Landcruiser begin to roll towards a sheer drop with her son in the back seat. The vehicle stopped just before reaching the edge, but the woman was so frightened that she became weak and dizzy. She rested for a while and seemed to recover from the shock but later that evening she had very disturbed sleep. The next day she began to complain of dizziness and dropped plates and bowls while preparing the noonday meal. She began to complain that she was suffering from fija’ and after some discussion among her family, it was decided that her fright had brought on her illness. Later that evening she was suddenly grabbed from behind by her husband, and while she was held down. her brother applied a glowing hot iron to the back of her neck. After she stopped sobbing and wailing and began to recover from the second, counterbalancing shock. she went to bed and rested. The next day she had to contend with a severe bum, but was no longer suffering from the symptoms of fijac,
In this case the fija’ was directly associated with her subsequent changes in behavior; the illness state followed soon after actually experiencing a profound fright. According to the belief system, she was seen to suffer from an imbalance of her spirit or essence (nafs. rub) which generated her illness symptoms. This type of experience is probably the kind of ‘kernel of truth’ which generated and perpetuates the fright theory here as elsewhere. However, very few of the cases of fija’ follow this ideal pattern: a rapid manifestation of a limited set of shock induced anxiety symptoms and quick recovery after the counterbalancing shock. By far, most of the cases are retrospectively diagnosed after a considerable time period has lapsed. More typical examples of fija’ can be seen in a review of other case histories taken from the western central highlands region of Yemen. Ccrsr -7. This case mvolved a 25year-old woman who had been married for IO years. She had been pregnant three times; two male children were alive and one male child had died in infancy. She had delivered her last child 5 months prior to her visit to the hospital. Her father was a mason and her husband drove a tractor and had worked in Saudi Arabia off and on over the past IO years. Nevertheless. she described herself as a poor person (miskina). Her husband had been working in Saudi Arabia for just over a year and returned to Yemen because of her complaints of pain. The woman had been suffering abdominal pain and weakness with occasional vomiting for about one year. Clinically. she was diagnosed as suffering from gastritis. She, herself, described her condition as “a pain in the mouth of the stomach. that IS, the y&b” r23]. She attributed the cause of the illness to a fright (fija’). that she had experienced upon hearing of a young healthy man in the neighborhood who suddenly died after chewmg qat. The fright happened just after her husband had departed for Saudi Arabia. Over a year passed before she presented her problem to the doctor. although she had sought local religious treatment and had four amulets (hurt) written to counter the illness (at U.S.S50 each). Cuse _?.A 35year-old wife of a stone mason had complained of suffering weakness, cough, chest pain. and pain in the back for just over a year. She occasionally coughed blood. She had also recently given birth to another baby at the time of the onset of the symptoms. She described her illness as
an mabilny to do her work. especially fetching water and hauling heavy loads. She was tested and found negative for TB. and was diagnosed as suffering from chronic bronchitis. She attributed her illness to a tija’ from a car accident that occurred behind their house just after she had delivered her baby. when she was in a very weak state. One month before the visit to the clinic (almost a year after the onset of the symptoms). she had been taken to a neighbor who burnt her with red hot irons on the back of the neck and on the forehead. but it was not effective. Her brother-in-law was bringing his wife to the hospital so she had the opportunity and decided to come along and be seen by a medical doctor.
Case 4. A 27-year-old woman. a member of one of the lower classes in Yemeni society. came to the clinic with her female cousin. Her husband was an occasional potato broker. general laborer, and had worked in Saudi Arabia. but was now back in Yemen, again looking for work. Her father was a qat seller. She described her problem as a general weakness accompanied by chronic pain, especially in the liver, back. chest, and abdomen. She also had a chronic cough and fever. She was clinically diagnosed as suffering from pneumonia and was infected with intestinal parasites. She attributed the cause of the illness to a fija’ suffered when her brother was hit by a car some 6 years previous. though the brother was uninjured. She had been burned on the back of the neck after the first manifestations of the symptoms years earlier, but had no other treatments. She said she had been weak ever since the fijac, and that the onset of this manifestation of the problem was triggered by her delivery of a baby about 10 days before. In side notes, the medical doctor reported that the woman was concerned that her clinical illnesses might interfere with her ability to get pregnant again, and that she had stopped taking her medications because the women of her village told her the pills she was taking would prevent her from getting pregnant. Case I The case involved a 27-year-old married woman. Her husband, a mechanic. had been working in Saudi Arabia for the past year and a half. She came to the hospital suffering from difficult breathing and weakness, feeling “that her knees could not support her any more”. She also reported that “sometimes her heart would race faster and faster until she felt as if something had opened in her back”. She complained that the symptoms had been a problem for over 4 years. She was clinically diagnosed as suffering from gastritis with retrosternal pain. She attributed the onset of the problem to the death of her brother 4 years prior and the resulting fijai, In describing the fright and resulting condition she said “ruhi faira”. my spirit (or soul) fell down. She had been taken to a number of doctors throughout Yemen. Many people had advised that she be burned, but her father refused because of the pain it would cause her. Case 6. The case involved a 30-year-old woman who had yet to give birth to a child. Her husband was a migrant worker in Saudi Arabia. He has been working since before their marriage some I I years ago. HIS pattern was typical of most Yemeni migrant workers, staying away for 2 years and then coming home for 612 months before returning to find more work. She was uncertain of who was to blame for the primary sterility. She reported that she thought it might be a problem with her husband because he refused to take another wife and rumors had it that he was examined in Saudi Arabia and found to be sterile. She came to the hospital complainmg of painful intercourse and weakness. She described the parn she experienced during intercourse as “a fire going through her body, making her so weak that she was about to die”. She attributed the pain to the fact that she had been washing a heavy blanket before they had sex. However, a relative. an old masseuse suggested that the problem was from a fija<. A few weeks before coming to the clinic she was therapeutically burned twice, once on the solar plexus and once on the back. but the pain and weakness had not subsided
Yemeni fright illness These case outlines illustrate how fija’ is associated with wide ranging symptomatology. It includes general weakness, shortness of breath, dizziness, fitful sleep, chronic cough, fever, abdominal, chest and back pain, liver pain, and sexual dysfunction. The clinical diagnoses of these case examples also indicate a range of physical problems including gastritis, chronic bronchitis, pneumonia and intestinal parasites, primary sterility and painful intercourse. While a few symptoms such as general weakness and anxiety appear in several cases, these symptoms are so general that they do not provide enough significant basis for clinically defining a syndrome. Furthermore, the majority of the cases indicate such a considerable and variable time lapse between the reported fright and the onset of the various symptoms that causal connections are at best dubious. Rather than being an example of a culture-bound syndrome, the evidence indicates that fija’ is an ‘explanatory model’ which incorporates a wide range of illness symptoms [6]. Caution should be exercised in drawing broad generalizations on the basis of a few case studies, but the Yemeni data reveals significant similarities between fijac and other examples of the fright illness taxon. The phenomenology of fija’ involves a fright which creates an imbalance. This must be restored, often by a second shock. Similarly a common treatment for susto in Mexico also involves administration of a second, balancing shock such as a spray of cold water in the patient’s face [13] and Good and Good [16] report the use of burning as a counteracting treatment for fright illness in western Iran. The cases from Yemen also illustrates the widespread notion that there can be a significant time period between the alleged frightening event and the onset of the particular illness episode. Similar delays between fright and onset of symptoms are found in susto [I, 4, p. 1191. Thus, the similarities in illness ideology and the range of physical treatments suggests that a comparison of examples within the fright illness taxon may be useful. The social distribution of jright illness
A review of the various examples from the fright illness taxon indicates that fright as an etiological illness category tends to cluster among women, children, and lower class men [24]. In their earlier research O’Nell and Selby reported a significantly higher incidence of susto among women, and in western Iran Good and Good [16, p. 1.541 also indicate an asymmetrical distribution of the illness; women and children tend to be overrepresented. Similarly, Morsy [25,26] indicates that in Egypt both the fright illness tarba with its variable symptomology and as well as the folk illness ‘uzr, in which fright is presumed to have etiological significance, women, children, and lower class men are more likely to manifest the disorder. My data from the highlands of Yemen seems to conform to the same pattern. In addition to the case studies presented above, evidence drawn from the observations of health care development workers indicates that fijac is one of the most common etiological illness categories among Yemeni women. In their preliminary study of mother and child health in the rural mountains of western
385
Yemen, Johnson et al. [27] report that fija’ is one of the principal causes of illness offered by women to explain a range of maladies, and in their study of malnourished children Beaty and van Dijk [28] indicate that fright ranks just behind the ubiquitous ‘evil eye’ as a ‘supernatural’ explanation given by women to account for nonspecific illnesses. By contrast, in my interviews with 61 randomly sampled male heads of households in four villages, fijac was given as a cause of illness in only one case out of 439 reported illness episodes [29]. Fija’ was indicated as the cause of a case of qalaq (severe anxiety) experienced by a woman after the earthquake of 1982. The only case I recorded involving a male was a boy in his early teens who had tripped and had the wind knocked out of him; as he recovered his breath, his group of playmates again wrestled him to the ground and put a burning match to the back of his neck as a preventative measure before he could develop symptoms. In this survey, when asked to speculate on the causes of common illnesses, most tribesmen offered etiologies closely aligned with the causal factors articulated in the classical Arabian medicine and with the more cosmopolitan theories of causation. These data suggest that fija’, like susto, is much more likely to be a diagnosis made by women for conditions suffered by women and children. While the number of case studies is not yet sufficient to support generalized conclusions based on comprehensive hologeistic research, the ethnographic evidence is strong enough to warrant the construction of some tentative explanations for this sociocultural profile. An answer to the question why illness experiences are expressed in the fright illness idiom by one segment of the population and not another may be found by employing the analytical notion of patient explanatory models (EMS) [6, pp. 104-l 181 as evidence of medical knowledge, and by looking at social, and cultural factors which may affect the distribution of medical knowledge in society. In seeking an explanation for the relative absence of fright illness among men, a good place to start is the cultural value systems [30]. Societies with an apparent concentration of fright illnesses among women and children also maintain a value system that emphasizes a ‘macho’ type of male social role in which the male. as the protector/provider of the household. should be strong, powerful, and dominant. This is clearly evident in the comments of the Zapotec woman mentioned above. In Yemen society social status is carefully defined and maintained. At the upper end of the ascribed status ‘hierarchy’ are the religious elites (sa_vyid-sand qadhi-s) while at the lower ends of the hierarchy are the nontribal ‘Arabs’ (Bani Khums, nuqqas) and the descendants of nonArab groups such as former state servants (akhdam). However, the core of Yemen society is composed of the tribesmen (qabili-s), descendants of the noble South Arabian tribes [31-331. In tribal Yemen, the ideal male role is embodied in the tribal ethos (often reported as qabayla). In her detailed analysis of qabayla Adra observes that “the ideal qabili (tribesman) is courageous, generous, recognizes his obligations toward proteges, is faithful to his word, and has a strong sense of justice. The qabili is also strong,
CHARLES F. SWAGMAN
386
hardworking, and a man” [34]. Consistent with my findings on fright and illness, she also reports that: The importance of courage in tribal identity. is expressed also in attitudes towards fearfulness, which is considered a dangerous state to be avoided at all cost. Fright is considered to lead to a pathological state called fija’ (torment, misery). A person who has been frightened as a result of a fall, from witnessing an accident or near accident, or even from an imagined danger becomes agitated and distracted and may complain of heart palpitations or trembling hands, symptoms of fija’. These symptoms are taken seriously and treated by touching a predetermined part of the body (usually the back of the neck) with a burning brand. Thus, fearfulness is. in tribal world view, physical. It is not something that can be avoided or overcome by conscious control. Only one’s physical stamina determines whether or not one can be frightened easily, and measures are taken to protect the weakhearted from exposure to frightening situations. Some women will not walk along between villages at night. and infants are not taken outdoors at night because it 1s assumed that they will be frightened (34, pp. 1461471. The emphasis
on the ideal
of strength
and
courage
in
Yemen tribal society may provide part of the answer to the question why fija’ is rarely reported by men as an illness category. To admit to suffering from fright is to admit to a weakness that challenges the very essence of being a tribesman. If a man is not perceived of as courageous and strong and able to protect his family and property, his sense of self, his social status as a man, and by extension, his identity as a tribal warrior is at risk [35]. Therefore, men may elect to cast their illness experiences in alternative cultural idioms that do not imply any basic character weakness. Yemeni women, on the other hand, are generally regarded as weak and vulnerable to external threats. Falling victim to illness precipitated by fright is consistent with the cultural definitions of female identity. Given the complexities of human behavior, very often multiple factors are operating at any one time to influence health related behavior. Thus, explanations can be postulated at multiple levels without necessarily contradicting or cancelling the other. A second. and complementary explanation may be found in examining how cultural attitudes and values affect the availability and distribution of form of medical knowledge. especially in a changing cultural environment. In Yemen tribal society most social relations are conceived of in terms of honor (sharuf, ‘and. H@) and shame (‘u~b) (34, 36-381. Of primary importance in retaining social standing is the maintenance of tribal and family honor. As in most Arab culture. tribal and family honor is symbolized most visibly in the virtue of the women, and social conventlons are elaborated to insure its preservation [39.40]. In rural Yemen these conventions include such behaviors as veiling and segregation by sex in any public or semi-public forum. Additionally, women’s social and physical space is limited to that in which honor can be defended, that is, the household and local community, and tribal land. In opposition to these protected spaces are public places where honor is seen as highly vulnerable, especially the market (suq). Given that most educational, health. and government facilities have been located in or around major commercial centers, Yemeni tribal
women have had very limited access to these sources of medical knowledge. Following the 1962 overthrow of the thousandyear Zaydi Immamate, Yemen’s end to centuries of isolationism resulted in new opportunities for socioeconomic and cultural change. Access to new forms of medical knowledge through channels such as formal education and printed media, military service. emigration to neighboring oil producing countries. as well as the direct exposure to cosmopolitan health care facilities that these opportunies afforded. was concentrated among males from the higher social status categories. As a consequence of these socioeconomic and cultural changes Yemeni women and young children (and lower class men) have limited exposure to alternative (i.e. cosmopolitan) health care ideologies. Yemeni women, who are very restricted in their social space and whose channels for information are circumscribed tend to be more traditional and conservative in the range of cultural beliefs offered to explain illness (411. In contrast to the ‘modern’ explanatory models offered by Yemen men, the women interviewed offered etiologies more closely associated with pre-Islamic, supernatural, and specifically Yemeni folk beliefs: their range of ideas about health were more narrowly confined to those held by and transmitted within the members of their immediate social world. Thus. differences in social relations and potential life experiences have resulted in differences in the general ideologies held by Yemeni men and women. Fija’ is one of the central etiological illness categories in the indigenous health care belief system. It may also be argued that women (and lower class men) associate fijaL with illness more often than men because of the absence of competing alternative explanatory models. As fija’ is one of the most prominent explanations that can bc attributed to a wide range of illness states, it is reasonable to hypothesize that the highest incidence would be found among those members of Yemen society whose medical explanatory models are most limited to indigenous forms of knowledge. CONCLUSION
The work of Simons and the contributions of the more ‘meaning centered’ analysts has helped to reshape much of the thinking about the fright illness taxon. When no longer considered as specific syndromes or disease objects. these nebulous folk illnesses become amenable to different approaches which may better account for their particular sociocultural profiles. People with illness symptoms, through negotiation with a healer. rheir family members, or through process of self-reflection and rationalization within the medical behef systems. settle upon satisfactory explanations that attribute illness experiences to specific causes: the result is a complex illness profile in which a variety of clinically defined states may be attributed to a single cause such as fright. The social distribution of specific folk illnesses like fijac may be reinterpreted to be a reflection both of the distribution of medical knowledge in culture and of cultural values. In sum. it is suggested that explanations for the patternmg of folk illnesses may
Yemeni be improved by taking into account the social relations that affect the distribution of medical knowledge in addition to the customary analysis of possible factors (e.g. psychosocial stress) that might contribute to clinically definable illness states that are cast in local folk-illness idioms. am particularly indebted to Fatima Zuhra Woehlers-Olsen Kaserat, M.D., M.P.H. for her cooperation in administering the outpatient questionnaires from which the case examples were drawn. The research was conducted between 1982 and 1984 while I was the medical anthropologist for the Dhamar Governorate Health Services Programme in the Yemen Arab Republic; however. the views expressed in this paper are solely the author’s, I would also like to thank Dr John G. Kennedy for his many helpful comments in the development of this paper.
fright
18. Simons R. A feasible and timely enterprise:
,9.
20.
Acknon~ledgemenrs--I
21.
REFERENCES
22.
Simons R. and Hughes C. (Eds) The Culture-Bound
5. 6. 7. 8. 9.
IO.
11. 12.
13. 14.
15. 16.
17.
Syndromes. Reidel, Dordrecht, 1985. Hahn R. A. Culture-bound syndromes unbound. Sot. Sci. Med. 21, 165-171. 1985. Klein J. Susto: the anthropological study of diseases of adaptation. Sot. Sci. Med. 12, 23-28, 1978. Rubel A. J.. O’Nell C. and Collado-Ardon R. Susfo: A Folk Illness. University of California Press, Berkeley, Calif., 1984. Bolton R. Susro: hostility and hypoglycemia. Ethnology 20, 261-276, 1981. Kleinman A. Patients and Healers in the Context of Culture. Umversity of California Press, Berkeley, Calif., 1981. Trotter T. Susto: the context of community morbidity patterns. Elhnology 21, 215-226, 1982. Simons R. C. Introduction to the fright illness taxon. In The Culture-Bound Svndromes (Edited bv Simons R. and Hughes C.). Reidel. Dordrecht, 1985: Murphy H. B. M. Notes for a theory on latah. In Culture-Bound Syndromes, Erhnopsychiatry, and Alternate Therapies (Edited by Lebra W.). The University Press of Hawaii. Honolulu, Hawaii, 1976. Ohnuki-Tierney E. Shamans and Imu: among two Ainu groups-towards a cross-cultural model - of interpretation. In The Culture-Bound Svndromes (Edited by Simons R. and Hughes C.). Reidel, Dordrecht, 1985.. O’Nell C. W. An investigation of reported ‘fright’ as a factor in the etiology of susto, ‘magical fright.’ Efhos 3, 41-63. 1975. O’Nell C. W. and Selby H. A. Sex differences in the incidence of susto in two Zapotec pueblos: an analysis of the relationship between sex role expectations and folk illness. Ethnology 7, 95-105, 1968. Rubel A. J. The epidemiology of a folk illness: Susro in hispamc America. Efhnology* 3, 268-283, 1964. Hart D. V. Lanti. illness by fright among Bisayan Filipinos. In The Culrure-Bound Syndromes (Edited by Simons R. and Hughes C.). Reidel, Dordrecht. 1985. Frankel S. Mogo Laya. A New Guinea fright illness. In The Culrure-Bound Svndromes (Edited by Simons R. and Hughes C.). Reidel, Dordrecht, 1985.. Good B. and Good M. J. D. Toward a meaning centred analysis of popular illness categories: fright illness and heart distress in Iran. In Cultural Conceptions of Mental Healrh and Therapy (Edited by Marsella A. 1. and White G. M.). Reidel. Dordrecht, 1982. Prince R. and Tcheng-Laroche F. Culture-bound syndromes and international disease classifications. Culr. Med. Psychiat. II, 3. 1987.
illness
23.
24. 25.
26.
27.
28.
29.
30.
387
commentary on “culture-bound syndromes and international disease classifications” by Raymond Prince and Francoise Tchgeng Larouch. Cult. Med. Psychiat. 11, 21. 1987. Rubel A. J. er al. The folk illness called Susfo. In The Culture-Bound Syndromes (Edited by Simons R. and Hughes C.). Reidel, Dordrecht, 1985. Stedman’s Medical Dictionary. 24th edn. Williams & Wilkins, Baltimore. Md, 1982. defines a syndrome as “the aggregate of signs and symptoms associated with any morbid process, and constituting together the picture of the disease.” Additionally. DSM III-R defines a syndrome as “a group of symptoms that occur together and that constitute a recognizable condition,” p. 405. Central to each definition is the idea that a syndrome is identified on the basis of a recognizable set of symptoms. Due to the wide variation in symptomatologies the examples from the fright illness taxon do not meet the basic requirements to be classed as syndromes. Jilek W. G. and Jilek-Aall L. The metamorphosis of ‘culture-bound’ syndromes. Sot. Sci. Med. 21, 2055210. 1985. Browne E. G. Arabian Medicine. The University Press. Cambridge. 192 1. In Yemeni dialect the word qalb literally means heart, but in general terms, the word also simply means center. For example. the center of a motor is the qalb, as is the main point of an argument. It is quite similar in usage to the English terms for heart. Morsy S. Sex roles, power and illness in an Egyptian village. Am. Efhnol. 5, 137-150. 1978. Morsy [24] argues that class is an important factor in the incidence of the Egyptian condition ‘uzr. and that women are particularly susceptible. Good and Good [16, p. 1541 present a table that indicates a loading of cases of fright illness among women and children in Iran. Additionally, the work of Rubel [13] and O’Nell and Selby (121 also indicate this. Morsy S. Gender, power and illness in an Egyptian village. Ph.D. dissertation, Michigan State University, 1978. Johnson C. O’Reilly M. and Soutar D. A baseline health study of three areas in al-Ja’afariya District. Unpublished field report. British Organization for Community Development. Yemen Arab Republic. 1985. Beaty S. and Dijk R. van. Determinants of childhood malnutrition. Unpublished manuscript. Dhamar Rural Health Proiect. Yemen Arab Reoublic. 1987. Structured *interviews were conducted among 25% of the male heads of household in four villages in western Anis in which details of recent family illnesses. folk etiologies. treatment choices and decision making procedures were elicited. To select the sample. a list of all heads of households was provided by the village tax assessor or shaykh and the respondents were selected by use of a random numbers table. All four villages were similar in size. ecological zone. and distance from cosmopolitan health facilities. See Swagman C. F. Health culture and change: health care development in highland Yemen 1988 (unpublished manuscript) for a more detailed discussion of the structure of Yemen health beliefs. The Beaty and van Dijk study was also conducted in Dhamar province and included some of the same villages in Maghrabet al-‘Anib involved m my research. In this article the argument has been to explain why a common illness category is not frequently expressed by men, rather than examining the question from the complementary position of why it is often used by women. In contrast to Boddy’s (1988) work on Sudanese zar, where she accounts for its high prevalence among women through an analysis of the female ‘self’, the susceptibility to fright does not seem to be grounded
388
CHARLES F. ^~WAGMAN
in gender identity. In the vernacular ideology, all people can be subject to fright, and in fact, are. Thus, the emphasis on the negative case, the denial aspect of men, seems to be the more reasonable course of analysis. T. Market Mosque and Mufraj: social 31. Gerholm inequality in a Yemeni town. Stockholm Stud. Sot. Anrhrop. 5, 1917. 32. Stevenson T. Et. Social Change in a Yemeni Highland Town. University of Utah Press, Salt Lake City, Utah, 1985. 33. Swagman C. F. Development and Change in Highland Yemen. University of Utah Press, Salt Lake City, Utah. 1988. the tribal concept in the central 34. Adra N. Qabayla: highlands of the Yemen Arab Republic. Ph.D. dissertation, Temple University, 1982. Sudan: the 35. Boddy J. Spirits and selves in northern cultural therapeutics of possession and trance. Am. Eihnol. 15, 421. 1988.
36. Caton S. Salam Tahiya: greeting from highland Yemen. Am. Ethnol. 13, 29&308, 1986. 37. Dresch P. The position of Shaykhs among the northern tribes of Yemen. Man 19, 31-49, 1984. 38. Dresch P. The significant of the course events take in segmentary systems. Am Erhnol. 13, 309-324, 1986. 39. Dorsky S. Women of ‘Ammn. Universitv of Utah Press. Salt Lake City, Utah, 1986. 40. Makhlouf C. Changing Veils: Women and Modernizarion in Norrh Yemen. Croom Helm. London. 1979. 41. As an example of the notion that women in rural Yemen are, in a sense ‘keepers’ of historically deep beliefs. it has often been noted that the women speak a dialect of Arabic that can be quite localized and relatively uninfluenced by outside dialects. In Jibal Rayma there were a number of linguistic markers, such as the use of kafas a future prefix and the use of kaf as the final consonant in the second person masculine perfect form of verbs.