General Expectations and the Effects of Unshared Culture

To this point, attention has been directed to the nature of Swahili culture, the extent of its sharing, and some fundamental processes that promote the differentiated conformity called for by the distribution of culture inherent in a social structure composed of articulated statuses. The issues still to be examined all concern the ways culture actually affects what community members do. These include how cultural elements affect individuals who do not share them, how cultural elements are organized, including given priorities, and how individuals use cultural elements and products to pursue goals whether they are aware of doing so or not.

Chapter 9 discusses how those who understand themselves as ill find medical treatment. Understandings identifying the signs of illness are widely shared, as are beliefs holding that a wide variety of kinds of medical care are available in Mombasa and that getting some kind of treatment can be beneficial.

In trying to understand how culture provides guidance in getting care for the sick, an obvious hypothesis, based on the customary invocation of "shared beliefs and values," is that the sick use an intrinsically organized schema of shared understandings as a guide to dealing with their illness. It begins with their recognizing themselves to be sick, proceeds through understandings about what to do when sickness of the kind they attribute to themselves is present, and leads to visiting medical practitioners whom they understand to be able to deal with the causes of their illness as they understand them.

In fact, the connection between the understanding that one is sick and the decision about what kind of physician to visit is only rarely composed of intrinsically related cultural elements of the sort mentioned in the hypothesis. Contrary to the hypothesis and quite different from the sorts of schemata used by, say, chess players, the common schema for sick Swahili is most often extrinsically organized.

Patients are found to have only the most limited understandings about body functioning and illnesses, and although most know there are many sorts of medical practitioners in town, they have few understandings about the nature of differences among them. The basis for their decision about what treatment to seek is usually the advice they receive, so that this advice is the basis for the connection between the understanding that they are ill and the decision to consult one sort of practitioner rather than another.

Given the central part played by the advice, it follows that their expectations of the adviser, since that is what makes the advice useful, are central to their treatment-seeking schema. Since the expectations involved in the relations between people are elements of the statuses they occupy, for the great majority of community members who do not share most medical understandings, it is the status system that makes that part of the group's culture effective.

Chapter 9 describes the elaborate set of understandings shared among practitioners of what some group members refer to as "traditional Swahili" medicine. These understandings are shared among professional practitioners and also among what I discovered was only a small, but articulate, group of dedicated amateurs. It is part of Swahili culture since a number of group members share it with one another, but even its main outlines are unknown to more than three-quarters of the group. Nevertheless, it is a functioning part of the culture that affects most group members at some time—often many times—in that it affects what treatment they receive when they are ill.

This is a case, then, of cultural elements affecting those who do not share them. There is nothing unusual about this; much of what happens in all groups depends on members being affected by cultural elements they do not share. The way Swahili patients get treatment, however, offers an opportunity to examine the process whereby cultural elements can influence even those who do not share them. In this case, the vehicle for the effects of unshared culture is advice that is followed, and the acceptance of that advice is the result of the expectations in the role involving the patient and the adviser.

My investigation showed that the adviser was a parent for a substantial majority of those who lived with or very close to one or more parents and a spouse, neighbor, or kinsman for the remainder. The patients said that they followed the advice they got either because the advice giver "knows about illness" or because he or she had had a similar illness and reported being

helped by the practitioner recommended. On interviewing as many advisers as I could, I found that only about half themselves shared the basic understandings about body functioning and illness that would make an intrinsically organized illness-treating schema possible. The advisers, in many cases, were themselves advised in finding the practitioners they recommended; whole chains of advice expand the reach of the medical understandings to those who do not share them. This proves to be as true of understandings about and use of Western medicine as it is of traditional Swahili medicine.

For most patients, what is crucial to their getting the medical treatment they do are the expectations in the advisers' statuses and their part in their roles vis-à-vis the patients. As with Fernandez's (1965) ritual attenders who shared few understandings about the ritual they participated in with the specialists who arranged and staged the ritual, the patients' behavior is to be understood as a product of the understandings that connect statuses rather than directly as guided by the understandings concerning the immediate focus of the actual behavior.

As noted earlier, the distribution of understandings among statuses includes general expectations as well as specific ones. Patients told me, for example, that they followed their mothers' (and in a few cases, their fathers') advice about getting treatment because "my mother knows about these things," because "she is concerned about me and my health," and similar reasons. The patients "trust," "believe in," or (in a few cases) "obey" their adviser, and these views are rooted in general expectations about the adviser as part of the adviser's status as parent, spouse, kinsman, or neighbor. The adviser, in turn, has general expectations regarding whomever he or she found out about the therapist from. The intersection or connection of the general expectations in the different relationships (i.e., the adviser's direct or indirect trust in the therapist's ability and the patient's usually direct trust in the adviser) leads the patient to get treatment from a person whose relevant status is based on understandings shared with other therapists and with a few interested group members but often not with the patient.

It is the relationships among people guided by elements in their statuses, most especially general expectations, that lead the patient to seek and accept the treatment. If we think of social structure as the connections among statuses based in the mutual referring understandings that constitute those statuses, it is social structure, a product of culture,^[8] rather than the cultural elements concerning illness and treatment acting directly as a guide to behavior that accounts for what is observed in at least some group members' choice of therapy and therapists. Culture's elements, concerned with who trusts who as well as with who has understandings about the sources of illness or who is an acceptable therapist, are distributed among the statuses, and the distribution itself has a key part in the phenomenon of consulting a particular therapist.