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Social Isolation, Cultural Competence, and Disability in the Carolines

By Mac Marshall

January 1994 (MC #13) Cultural Health Social Issues

Introduction

Most contemporary anthropologists define culture as a socially constructed, learned communicative code based on a shared system of meaningful signs. In order to acquire and manipulate this code, human beings everywhere rely very heavily on hearing and speech; culture learning is at once aural and oral. It follows that human beings everywhere ought to find anything that interferes with normal hearing and the development or maintenance of normal speech to be threatening because it might inhibit or even prevent cultural transmission. Persons without culture are genuinely disabled.

Identifying common psychiatric themes in Polynesian and Micronesian cultures, one anthropologist notes that "the fear of social isolation, not only in the sense of social rejection and withdrawal of support, but in the literal sense of being physically left alone," is a cause of anxiety. In these societies self-imposed isolation is a common symptom of the onset of mental disturbance, and isolating oneself from the community, either socially or physically, carries a particularly powerful message. To accentuate the centrality of the group over the individual in Polynesian and Micronesian social life, virtually every anthropologist who has worked in these islands has emphasized the importance of external social controls over internal personal controls in maintaining behavioral conformity. Polynesian and Micronesian communities are group-centered and their members are other-directed. The person in these island communities exists not so much as an autonomous self (as in the West), but rather as part of a larger community of selves. This group-oriented rather than individual-oriented view of the person presents a challenge to the concept of "disability" that has been adopted by the World Health Organization and is widely used in the West: "any loss or abnormality of psychological, physiological, or anatomical structure or function."

In what follows we will question the Western concept of "disability" by examining the ideas Carolinian atoll dwellers hold about personhood. Specifically, we must distinguish between impaired parts and impaired persons. These islanders do not see most physical impairments (impaired parts) as "disabilities." This is because in most such cases the individual is able to continue active, even if limited or reduced, participation in the on-going everyday network of social relationships. Even "serious" physical impairment (eg, quadriplegia or blindness) is not necessarily a "disability" in these atoll communities as long as the impaired person can construct new roles that permit active contributions to household and community life.

The anthropological material on Caroline islanders supports a position that the concept of disability should be limited to those chronic or permanent conditions in which the self is socially isolated--in which the person either no longer wishes to be or no longer can be constructively enmeshed as an involved participant in community life. In Carolinian atoll communities, then, it is primarily various sorts of psychological, psychiatric or "mental" conditions that are disabling. This focus on psychological conditions leads us directly to local concepts of personhood.

Personhood and Competence

The richest discussion we have of personhood in Carolinian atoll communities comes from the anthropologist Catherine Lutz. On Ifaluk, she observes that "the most fundamental need of persons is to be with other people." Of the atoll's 430 inhabitants, only one senile 70-year-old man lived alone. Lutz states that "the ethnopsychological beliefs that surround and structure Ifaluk emotional life include the notion that the person is first and foremost a social creature and only secondarily, and in a limited way, an autonomous individual." This is echoed by Peter Black, writing of Tobi, "in which so much of the self is located in relationships," and where "a very important dimension of personhood is the place of the individual in the network of hierarchical and interconnected social relations." While Ifaluk individuals are recognized to have tip (meaning "will/emotion/desire"), "the mature self is one that is moved quite directly by others." Lutz summarizes this by offering the general principle that "the mental state of any mature individual is seen as having fundamentally social roots."

On Namoluk, I was told that tip is located in the area of the solar plexus, or what can be called "the gut." The Carolinian atoll dwellers traditionally have seen the gut as the seat of thought, feeling and will. Perhaps we should call this "gut-level awareness!" Lutz comments that the gut is viewed as "the link between mind and body, or, more accurately, as the core of the self in both its physical and mental functioning."

Pointing out that "speech is attributed great power and importance" on Ifaluk, Lutz claims that "the overt expression of mental events is a mark of maturity. Children and the mentally ill are said to be marked by problems with such expression; they do not talk about their thoughts or emotions." To children and the mentally ill, Lutz later adds the mentally retarded, the deviant, and the senile. All of these categories of persons on Ifaluk are labeled bush ("incompetent/crazy"). This is significant both regarding personhood and as it concerns the concept of disability.

The incompetent have, according to some informants, 'different insides.' Depending on both the informant and the incompetent individual in question, it is sometimes said that it is possible to be 'socially intelligent inside' but unable to express that understanding in language.

Thus, someone who once was culturally competent (in the sense of having "social intelligence inside" and being able to express it verbally) might become incompetent at a later point in life. For example, a person might have a severe stroke that affects intelligible speech, become psychotic and "speak nonsense," or suffer from senility and rave incoherently. Individuals who become "incompetent or crazy" in this way are disabled because they are cut off from regular human discourse. They are also at least potentially cut off from culturally constructed moral social relations that are "at least partially dependent on the understanding that permits virtue or the virtue that permits understanding."

The statement quoted above also helps us understand why children are included as bush. As Lutz notes, "the child may have a 'thought/feeling inside' but be unable to express it; the adult freely speaks about most thoughts and feelings." Young children often are incompetent to fully or clearly express themselves verbally, even if they have "social intelligence inside," since it normally takes children several years to master the language. On Namoluk this aspect of early childhood is summed up by use of the phrase mereit (they are not competent and therefore not responsible for their actions). This seems to be the Namoluk equivalent of the Ifaluk word bush. Lutz writes that, as with others to whom the word bush is applied, "young children, being crazy, are not considered responsible for their actions." In this sense, those who are "disabled" in Carolinian atoll communities lack social and moral responsibility, or are not held accountable for their actions because they are judged "incompetent."

Bush is the opposite of "social intelligence." Lutz makes it clear that for Ifaluk people "incompetence/craziness" ultimately is based in inappropriate behavior ("a lack of mental and social competence"). While the word bush is applied to certain kinds of crazy behavior that occur for what are seen as understandable reasons (eg, senility, excessive grief, intoxication, and spirit possession), it is worth quoting Lutz at some length here because her discussion bears directly on my argument:

Crazy people behave in ways that indicate they have incorrectly perceived the situation they are in and so do not feel, think, or act appropriately. A person may be crazy in several senses. Some people are born crazy and, although their primary failing is their inability to perform adult work, they also often engage in much otherwise inexplicable behavior, such as violence, shouting, or a lack of table manners. There have been cases in the past in which a person was said to have gone crazy for months or even years and then returned to a socially intelligent state. In some cases, the cause of the episode was said to have been an intense emotional experience...

People who are otherwise socially intelligent may sometimes do things which earn them the label of craziness on a very short-term or even metaphorical basis...the term can be used to describe anyone who is behaving in an irrational and unadult manner. To say that someone is crazy is to say that his behavior has no other reasonable explanation. It is also at least temporarily to write that person off as one whose behavior is beyond the pale.

Anthropologist William Alkire mentioned a Carolinian theory of knowledge and intelligence in which wisdom, knowledge and intelligence are grounded in hearing and speaking. We have seen above that competent persons are able to hear (in the sense of comprehend) and to speak. The "incompetent or crazy" either cannot hear and/or speak or cannot communicate intelligibly even if their auditory neurons and their vocal cords are functioning properly. This emphasis on hearing also is relevant to the way people of Chuuk describe drunks:

Drunks are referred to as crazy; they are likened to animals and they cannot or will not hear or listen to others. This notion of drunkenness as crazy, animallike behavior where the basic human capacity for reason is stripped away (one cannot reason with a drunk because he cannot hear) is fundamentally important for comprehending the Trukese attitude toward liquors and the behaviors of those who have consumed them. [Marshall, Weekend Warriors]

Personal competence in these societies is contingent upon a continually demonstrated ability to respond to others, to be a mature adult, and not to be governed by tip (one's personal wishes or will). To be incompetent is to be crazy--to be beyond reach of the social universe that provides order and maintains the behavioral conformity (such as, control of aggression) necessary for successful life in these very small face-to-face communities. All persons are born "incompetent," but most become competent members of society through socialization (which on Ifaluk and elsewhere in the Carolinian atolls rely heavily on lecturing over spanking and other forms of physical punishment in keeping with the importance given speaking and listening). The exceptions are the mentally retarded, at least some of whom may be sufficiently endowed to operate at a quasi-competent level. Persons who have achieved competence may become "incompetent/crazy." Sometimes such "craziness" is only temporary, as in drunkenness or in spirit possession; at other times it seems permanent, as in psychosis or other chronic mental disturbance. Senility is usually irreversible once it sets in, but the "incompetence/craziness" associated with mental illness, while usually chronic, also is sometimes reversible. From this perspective, then, we would expect disabled persons from Carolinian atoll societies to include the chronically mentally ill, those elders suffering from senility, and possibly some persons born deaf and/or mute. At the same time we would not expect most individuals who are physically impaired from birth defects, accidents or diseases necessarily to be thought of as "disabled" unless the impairment was coupled with an inability to speak and/or hear--that is, with an inability to manipulate culture and to participate in the social life of the community.

The Causes of 'Incompetence/Craziness'

Widespread throughout the islands under consideration here is the belief that most diseases, tribulations, and misfortunes--ranging from injuries to suicide attempts--come from a number of supernatural sources, including sorcery, supernatural punishment, and unprovoked acts by "spirits." Far and away the most common source of such human afflictions are "spirits." The actions of "spirits" result in human morbidity and mortality; "spirits" also are held responsible for chronic "incompetence/craziness"--in other words, for what is here called disability from a Carolinian perspective.

On Lamotrek and Woleai, William Alkire writes that "congenital afflictions, crippling diseases, and accidents have all resulted in physical impairments that affect mobility, agility or appearance. There is little evidence, however, that such afflictions per se seriously affect an individual's status within the society." The examples he provides in support of this all involve persons who, despite their physical problems (congenitally atrophied leg, elephantiasis/filariasis, leprosy, one arm lost in an accident, polio, severe curvature of the spine), to actively participate in were able to actively participate in social relationships.

Alkire found that generally Lamotrek and Woleai persons with mental impairments (particularly mental illnesses) were "treated with greater caution, circumspection, or fear than physically disabled individuals." He accounted for this by the fact that people regularly attribute mental illnesses to punishment by "spirits," often for the violation of an important taboo. Finally, Alkire argues that "disabilities that affect intelligence and social interaction are viewed as more serious than ordinary physical disabilities."

Both Alkire and Melvin Spiro refer to nine traditional classifications of diseases on Central and Carolinian atolls. One of these, which Alkire lists for Woleai and Lamotrek as sigalabusholag involves the possession or "theft" of an individual by "an evil or thieving spirit" which results in crazy behavior. This seems to be the same disease category that Spiro labels malebush: "a generic term for all behavior that seems queer or deviant from the native point of view." I contend that this is the disease category that encompasses what might be called "true disability" in Carolinian atoll communities.

Rethinking "Disabilities" on Namoluk

In a paper I prepared last year on Namoluk case material I used Western categories of disability. This led me to discuss cases under the following headings: Mental Illness; Mental Retardation; Visually, Hearing and Speech Impaired; Restricted Mobility; and Other Medical Disabilities. Using these Western categories I identified 24 separate cases of impairment from Namoluk (representing 16 different individuals). This comprised four percent of the 1971 ethnic population. I now think this classification of disabilities was inappropriate because it failed to take account of local categories and understandings of personal competence.

In reassessing my imposed categories from last year in light of the discussion of personhood above, I find that the number of cases that the Namoluk people would recognize as "truly disabled" shrinks from 24 to three. Let us examine these cases to understand why and how I have made this change.

I now believe that five of the six cases I had listed as disabilities under the Restricted Mobility category probably were not judged "incompetent/crazy." These individuals all were actively involved in community life, even if at a reduced level from most people. The only one of these cases that I think still qualifies as "incompetent" (but not "crazy") is that of a 57-year-old married male with a chronic degenerative condition that appeared to be Parkinsonism (he died in mid-1972 at age 58). This man had been a highly respected community leader, having served as a lineage chief, as island magistrate and as an official in the local Catholic Church. He was esteemed and is still remembered as a gifted songwriter. His illness resulted in severe trembling and loss of muscle control so that he was unable to walk. This lack of mobility restricted him to his own homestead, which was located some distance from the main concentration of houses on the atoll, and he effectively "disappeared" from the island's social life. Until his death he was still able to hear and understand what was said to him, but it became increasingly difficult for those other than his wife and adult daughter (who were his caretakers) to understand his speech. Because he was "incompetent" but not "crazy," he might be thought of as quasi-disabled.

Of the four cases I classified last year as Other Medical Disabilities, only one still qualifies for inclusion upon this rethinking. This is the case of a baby born with multiple severe internal birth defects who lived for two years. This child never acquired language or cultural understanding, and never achieved "competency." He was born and died "incompetent/crazy." The same can be said for one case originally classified as Visually, Hearing and Speech Impaired. This was an infant girl born totally blind who died at around one year of age. I now believe that the other nine Visually, Hearing and Speech Impaired cases from last year's paper also no longer qualify as "disabilities." It is instructive to examine these to see why.

Six of them involve adults who were born with sight but who later became partially or totally blind, usually in mid-life or after. In no case did their blindness prevent their active involvement in island affairs, and all remained fully competent in speech and hearing. A seventh case involved a young man with a mild speech impediment that did not prevent communication; neither did it prevent him from graduating from the Community College of Micronesia and obtaining wage employment. The remaining two cases were born deaf. Both could make sounds but had not learned to speak. The one who was 11 years old at the time of my fieldwork had developed a reasonably effective means of communicating with her family and peers via gestures and facial expressions, and her family seemed to understand her fairly well. Despite their lack of hearing and speech, both children were well socialized into Namoluk culture and both actively participate in productive tasks. However, both are culturally "incompetent" (though definitely not "crazy") at the level requiring the ability to express one's "insides." They, like the man with Parkinsonism discussed above, are quasi-disabled.

The sole case classified as Mental Retardation in last year's paper also cannot be considered disabled. Despite his learning disability, he had a reasonable command of the local language, although his talk often rambled and didn't always make complete sense. Well integrated into his family and peer group, this young man has become a productive member of Namoluk society. He, too, is quasi-disabled.

This leaves us with the three cases that were classified as Mental Illness last year. By the criteria of personhood discussed above, all these are "incompetent and or crazy," and so are disabled.

Conclusion

Impaired parts--limbs, eyes, and even ears and vocal chords--do not necessarily make someone "disabled" on Namoluk and in other Carolinian atoll communities. At most, such physical impairment may render someone quasi-disabled, as in the cases discussed above. True disability on Namoluk and in these other communities only is recognized when the person is chronically or permanently impaired. This involves psychological or mental incompetency that places the person outside the community of shared moral discourse and/or isolates the person from active and productive participation in household and community activities. Disability on Namoluk and other Carolinian atolls is personal isolation (psychological and/or literal isolation) consequent on a failure of hearing (comprehension) and meaningful speech (verbal interaction). Of the chronically disabled, as of temporarily disabled drunks, it can be said: "they can't hear" or "they don't respond to spoken demands to comply with the community's moral precepts."

The measure of a person's "disability" on Namoluk, then, is the degree to which that individual is "incompetent/crazy." We can visualize this as a continuum. At one end are those with short-term or temporary "disabilities." This includes presocialized children, persons who are intoxicated, those possessed by spirits, and those subject to epileptic seizures. These persons are not seen as "truly disabled." Moving along the continuum we come next to individuals with disabled parts (a crippled limb, blindness). Only in very rare circumstances would these persons be labeled "truly disabled." Next are individuals with what Westerners would call major physical disabilities (seriously disabled parts), including paraplegia and quadriplegia for example. So long as these persons continue to be actively involved psychologically and morally in relationships with other community members, then they are not "truly disabled," although perhaps in some cases they might be what call "quasi-disabled." The next point along the continuum includes impairments that significantly cut people off from community life or that seriously compromise their ability to function psychologically as a mature, morally responsible person. The cases of the man with Parkinsonism and that of the young man with a congenital learning disability illustrate this point on the continuum; they are what I call "quasi-disabled." Finally, we reach the far end of the continuum where lies what I maintain that Namoluk and other Carolinian atoll dwellers recognize as "true disability." These persons have chronic or permanent mental or psychological disturbances of their person that isolates them and renders them "incompetent/crazy." Sometimes such persons overcome their disability; usually they do not.

Employing this view of disability, Namoluk aligns rather nicely with two other Carolinian atoll communities for which we have information on the number of disabled. Of the ten "disabled" persons on Ifaluk reported by an anthropologist in 1948, probably only four were truly disabled by the standard adopted here "incompetent/crazy." Three of these four were men. The data we have for Ulithi are not as detailed as those for Ifaluk and Namoluk, but Lessa and Spiegelman mention that there were only three psychotics out of the total population of about 400 in 1949. As with Ifaluk and Namoluk these mentally ill persons were all men. The "truly disabled" in Carolinian atoll communities generally appear to be few in number. It also appears that these mentally disturbed individuals are much more likely to be male than female. This accords with my "gut feeling" about gender differences and relative vulnerability to stress in these island communities. It is overwhelmingly males rather than females who use alcohol and other psychoactive substances (eg, marijuana) in Chuuk and the rest of these related island communities. In his paper on spirit possession, Hezel reminds us that suicide is largely confined to young males and that in Micronesia more generally male psychotics outnumbered females by a ratio of three to one. Again, an overwhelming "maleness" is revealed.

All of these threads, which cannot be pursued further here, suggest that males in Chuuk and the related Carolinian atolls are at considerably higher risk for "true disability" than are their female counterparts. If this proves so, then it has important implications for the development of prevention and treatment programs for the disabled in these island societies.

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