Bullet

A small spherical object enters your body; immediately it is a death sentence. Whether the death is imminent or prolonged, it is almost certain. Such is the nature of a bullet. In India, the word for a bullet is “goli”. A multifaceted word, it not only represents the idea of a bullet but also of a pill. Yet, the definition of “goli” in the context of medicine is somehow more damning than that of a bullet. How can that be possible?

Although society has experienced significant scientific progress in the treatment of diseases, we have not witnessed the same advancement in understanding the perceptions of disease and medical interventions for different types of people. Charles Darwin was key to revolutionizing this understanding when he first proposed his theory of evolution by natural selection in 1859. With a radical break from conservative scientific thought, Darwin contended that the organisms that have the best ability to pass on genetic material will do so, allowing for the propagation of that genetic material. While less widely known but equally as important, Darwin was also the first to propose the idea of sexual selection which posits that mates prefer specific traits causing those traits to be passed on from generation to generation. How does disease fit into these evolutionary schemas? In terms of natural selection, disease can reduce an organism’s fitness to survive, mate, and pass on genes. In terms of sexual selection, an organism may seek a mate who displays a healthy phenotype and may have an aversion towards an organism that displays a diseased phenotype to promote the likelihood that their progeny does not inherit the same diseasecausing genes. While all of this may not be in our conscious awareness in daily life, evolution’s subtle hand certainly guides our behavior.

The implications of a diseased phenotype or perception of a diseased phenotype have externalities that extend far beyond the self. This holds especially true in rural South Asia. In Eastern cultures, the idea of self is eclipsed by the idea of family. Osyerman et al show the differences in individualism between regions, with East Asia, Africa, and the Middle East scoring low on individualism scores and English-speaking countries like the United States and Canada scoring high on individualism scores (1). In measures of collectivism, the opposite held true: English-speaking countries, especially the United States, scored low on collectivism while regions like East Asia, Africa, and the Middle East scored higher on collectivism. In many regions, Eastern conceptions of collectivism take the form of the family unit and can be traced back decades. Evident in recent history, many young Japanese men fighting during World War II sacrificed their lives to become ‘kamikaze pilots’ to bring honor to their family name. For them, losing the war or giving up was not an option as it meant bringing shame to their family (2). In these collectivist regions, it is often that wins and losses are attributed to the family more so than the individual. Similarly, in rural South Asian communities, the mark of disease often damages the family image beyond just the individual. Since genes are inherited from parents and passed on to offspring, a single diseased phenotype colors the entire familial water.

This unconscious evolutionary tilt away from disease deeply pervades life. It is even ingrained into the language exemplified by the double entendre of “goli”. The SapirWhorf hypothesis of linguistic relativity describes how language can prime our thoughts and experiences of life. It is evident that the word “goli” is surrounded by a connotation of danger and harm, whether it refers to a bullet or a pill. In Southeastern Asian societies and Middle Eastern societies where arranged marriages may be more common, the aversion to disease and the appropriate medical intervention is also present in marital situations. Rather than a union between two people, marriage is believed to be a union between two families. Although it may not be recognized, ideas of sexual selection come into play here. Oftentimes even having a grandparent who is ill or even shows signs of illness can prove worrisome for the fitness of a potential spouse or suitor. Hence there is a culture of keeping details of one’s health within the bounds of the family. In general, the perception of disease is different. In these societies, disease implies a fundamental flaw in people as evolution may intimate. This is especially true in regions and cultures that champion ideas of karma and reincarnation. Karma is the concept that actions lead to consequences, namely good actions lead to good consequences and bad actions lead to bad consequences. If your actions are the sole catalyst of your fate, then you get everything you deserve. Even if you were born with a congenital defect, it can be explained by the karma accrued from your previous life, giving you personal culpability for your own disease. Therefore, the disease is not only seen as a diagnosis, but it is a condemnation that you are broken and, in some way, deserve to be. The entanglement of disease to life and self-worth creates tremendous pressure to reject modern medicine and reject the notion that your disease defines you.

The disdain for illness is paralleled by the disdain for subsequent medical intervention. A 2017 study by Nyblade et al interviewed 147 residents of Karnataka, India regarding cancer diagnoses and found that cancer stigma was prevalent due to the beliefs that cancer was contagious, people were responsible for their cancer, and that cancer was a terminal and debilitating illness (3). While stigma may exist, it is also important to understand the implications of this stigma and how it ties into healthcare-related decision-making. When looking at the location of deaths, countries in the Eastern Hemisphere like Pakistan and India have a significantly higher percentage of home deaths when compared with countries in the Western Hemisphere even when controlled for socioeconomic status. The study also mentions the cultural preferences these countries have for home deaths over inpatient deaths (4).

As far as modern medicine has come with fancy technologies and therapies, we still overestimate our ability to naturally overcome biologically hardwired biases and perceptions against disease. With end-of-life care becoming more complicated and treatments increasingly requiring social support and competency, we need to re-evaluate how the disease is viewed by different groups of people and how this may affect the treatment paradigm.

Prem PatelUMass Chan Medical School Class of 2027Email: prem.patel8@umassmed.edu