BIOCULTURAL ANALYSES OF SOCIAL STATUS, CULTURAL MEANING, AND CHRONIC STRESS HORTICULTURALISTS IN LOWLAND BOLIVIA AND URBAN PUERTO RICANS By ALAN FRANK SCHULTZ A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2014
Â© 2014 Alan Frank Schultz
To my mother, Nancy Ellen Schultz
4 ACKNOWLEDGMENTS First and foremost I thank my parents , Frank and Nancy, and my brother and sister, John and Angie , for their unwavering support of a restless youngest son and brother . I started working towards this goal after the death of my fath er in 2002 . T hrough tragedy I found the courage to follow my passions as he always did. Since that time I have had many wonderful academic and personal role models but none quite as influential as my PhD advisor, Lance Gravlee. I owe much of my personal and academic achievement over the last six years to his guidance, patience, trust and und erstanding. Thanks also to my exemplary PhD committee members Florence Babb, Alyson Young and Jeffrey Harman. Also at UF Russ Bernard and Chris McCarty gave invaluable help and guidance along the way. My passion for medical anthropology first developed in the University of Iowa in no small part d ue to her skill as a teacher . Her support continued long after I graduated and serves as an example of the support I try to offer my own students . Thanks also to Rudi Collore do Mansfeld, Virginia Dominguez, Mac Marshall and James Trostle who helped to shape my early understanding of anthropology. The faculty of the epidemiology program at the University of Iowa College of Public Health gave me rigorous trainin g from 2004 to 2006 and I am i ndebted to Neal Kohatsu , Audrey Saftlas and James Torner in particular for their support . My fellow students and colleagues at the University of Iowa Center for Human Rights, Students Against Sweatshops and the Domestic Violence Intervention Program of Io wa City stoked my passion to try to make change in the world. The members of ROADS have long served as great counselors and friends who continue to motivate me . Jennifer Baham, Juan Ruiz, Tom Stopka and Qiang Xia were wonderful mentors and colleagues
5 at the Office of AIDS in Sacramento, CA during my fellowship with the California Epidemiologic Investigation Service 2006 2008 . My cohort of fellows at the Cal EIS were also very supportive, especially Flojaune Griffin and Abby Becker. My time as a graduate s tudent in the department of anthropology at the University of Florida was enriched greatly by my fellow graduate students. I want to thank Yasemin Akdas, June Carrington, Joe Feldman, Camee Maddox, Meredith Marten, Brian Tyler, and Doug Monroe. Ricardo Go d oy and Victoria Reyes Garc Ã a introduced I had the good fortune of undergoing my acclimation to fieldwork with Asher Rosing er and Paula Tallman who remain good friends and colleagues. Tom Ã¡ s Huanca gave me crucial guidance in the field and E sther Conde Velasco provided a home away from home when I was in San Borja . Robin Mamani and Juan Pablo Ticona became great friends and essential colleagues who provided needed moral and tangible support for my research. Moseten friends and colleagu es were invaluable to my work. I especially want to thank my research assistants Orlando Durvano Tayo, Igna cio Huasna Tayo, and Dino Nate AÃ±ez . Manuel Hiza Jave taught me much about the Tsimane language. Candido Nery Tayo and Paulino Pache Lero of the Great helped me navigate reimbursements, permissions and innumerable other challenges . Finally, my sincerest gratitude goes to all the other administrators, colleagues and friends whom I have not mentioned by name but that were there to help and support me on this journey .
6 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 9 LIST OF FIGURES ................................ ................................ ................................ ........ 10 LIST OF ABBREVIATIONS ................................ ................................ ........................... 12 ABSTRACT ................................ ................................ ................................ ................... 13 CHAPTER 1 INTRODUCTI ON ................................ ................................ ................................ .... 15 Overview ................................ ................................ ................................ ................. 15 The Research Project ................................ ................................ ....................... 23 Research Design and Methods ................................ ................................ ........ 27 ................................ ............................ 36 Literature Review ................................ ................................ ................................ .... 44 Social Status, the Stress Process and Health ................................ .................. 44 Culture Change, Market Integration and Psychosocial Stress .......................... 54 Biological Anthropology and Adaptation Theory ................................ ............... 60 The Meaning of Inequality in a Non Industrial Society ................................ ..... 63 Market Integration and Indigenous Health ................................ ........................ 64 Bolivian Policy and Indigenous Health ................................ ............................. 66 Health and Well ................................ ..................... 78 ....... 80 2 PERSPECTIVES ON LIFE CHALLENGES AND SOCIAL SUPPORT AMONG FORAGER HORTICULTURALISTS EXPERIENCING RAPID CHANGE: AN EXPLORATORY MIXED METHODS STUDY ................................ ........................ 86 Overview ................................ ................................ ................................ ................. 86 Methods ................................ ................................ ................................ .................. 91 Research Setting ................................ ................................ .............................. 91 Participants ................................ ................................ ................................ ....... 92 Interview Design ................................ ................................ ............................... 93 Analysis ................................ ................................ ................................ ............ 95 Results ................................ ................................ ................................ .................... 96 Semistructured Interviews ................................ ................................ ................ 96 AjÃ: An Accessible Community ................................ ................................ .......... 96 Difficulties and Change ................................ ................................ .............. 96 Resistance Resources and Change ................................ ........................... 98 Social Stratification and Change ................................ ................................ 99
7 Serrucho: A Remote Community ................................ ................................ .... 101 Difficulties and Change ................................ ................................ ............ 101 Resistance Resources and Change ................................ ......................... 104 Social Stratification and Change ................................ .............................. 105 Uncertainty ................................ ................................ ................................ ..... 108 Less Time and New Demands ................................ ................................ ....... 108 Rankings of Problems and Social Support ................................ ..................... 109 Discussion ................................ ................................ ................................ ............ 110 Limitations ................................ ................................ ................................ ...... 113 3 MARKET EXPOSURE, CULTURE CHANGE AND INTRACULTURAL DEVIATION IN LIFE PRIORITIES AND SOCIAL SUPPORT: AN EXPLORATORY STUDY FROM LOWLAND BOLIVIA ................................ ......... 120 Overview ................................ ................................ ................................ ............... 120 Methods ................................ ................................ ................................ ................ 121 Rankings ................................ ................................ ................................ ........ 123 Ratings ................................ ................................ ................................ ........... 124 Consensus Analysis ................................ ................................ ....................... 125 Results ................................ ................................ ................................ .................. 125 Cultural Consensus Analysis: Life Priorities ................................ ................... 125 Cultural Consensus Analysis: Social Support ................................ ................. 126 Market Exposure and Cultural Models ................................ ........................... 127 Community Deviation ................................ ................................ ..................... 128 Deviation in Life Priorities ................................ ................................ ............... 128 Deviation in Social Support ................................ ................................ ............ 129 Discussion ................................ ................................ ................................ ............ 130 Limitations ................................ ................................ ................................ ...... 133 4 EVALUATING THE ASSOCIATION BETWEEN BLOOD PRESSURE AND A CULTURALLY MEANINGFUL STATUS GRADIENT AMONG FORAGER HORTICULTURALISTS ................................ ................................ ........................ 143 Overview ................................ ................................ ................................ ............... 143 Methods ................................ ................................ ................................ ................ 146 Research Setting and Sampling ................................ ................................ ..... 146 Participant Observation and Ratings Exercises ................................ ............. 148 Consonance in Life Priorities ................................ ................................ .......... 150 Blood Pressure and Covariates ................................ ................................ ...... 151 Statistical Analysis ................................ ................................ .......................... 153 Results ................................ ................................ ................................ .................. 154 Cultural Model of Life Priorities ................................ ................................ ....... 154 Consonance and Health Outcomes ................................ ................................ 155 Discussion ................................ ................................ ................................ ............ 157 Question One: Is individual consonance in shared life priorities inversely associated with blood pressure among a sample of indigenous forager horticulturalists? ................................ ................................ .......................... 157
8 Question Two: Does socioeconomic status change the nature of associations that might exist between blood pressure and consonance in this sample? ................................ ................................ ................................ 159 Limitations ................................ ................................ ................................ ...... 162 5 CULTURAL CONSONANCE, SUBJECTIVE SOCIOECONOMIC STATUS AND HEALTH IN SOUTHEASTERN PUERTO RICO ................................ ................... 173 Overview ................................ ................................ ................................ ............... 173 Methods ................................ ................................ ................................ ................ 177 Research Site ................................ ................................ ................................ . 177 Cultural Model of Lifestyle ................................ ................................ .............. 178 Participant Observation and Interviews ................................ .......................... 179 Consensus Ratings ................................ ................................ ........................ 179 Consonance ................................ ................................ ................................ ... 180 Covariates and Health Outcomes ................................ ................................ ... 180 Results ................................ ................................ ................................ .................. 182 Consensus ................................ ................................ ................................ ..... 182 Consonance and Health Outcomes ................................ ................................ 182 Discussion ................................ ................................ ................................ ............ 185 Local Cultural Models and Individual Consonance in Lifestyle ....................... 185 The Stress of Conflicting Status Expectations ................................ ................ 186 Limitations ................................ ................................ ................................ ...... 189 6 CONCLUSION ................................ ................................ ................................ ...... 195 Review of Stud y Aims ................................ ................................ ........................... 200 and Social Stratification ................................ ................................ ............... 200 Study Aim 2: To Describe Consensus and Variation in Cultural Models due to Market Exposure ................................ ................................ ..................... 202 Study Aim 3: To Compare Consonance in a Non Industrial Society of Horticulturalists versus an Industrial Society of Urban Puerto Ricans ................................ ................................ .............................. 203 Implications for Cross Cultural Research on Social Status and Psychosocial Stress ................................ ................................ ................................ ................ 205 Summary ................................ ................................ ................................ .............. 206 LIST OF REFERENCES ................................ ................................ ............................. 208 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 236
9 LIST OF TABLES Table page 1 1 Summary statistics from the epidemiologic survey including subsamples from the two ethnographic study communities. ................................ ........................... 85 2 1 Purposi ve life stage samples of semistructured interviews in accessible (AjÃ) and remote (Serrucho) communities. ................................ ............................... 118 2 2 Purposive life stage samples of rankings interviews in accessible (AjÃ) and remote (Serrucho) communities. ................................ ................................ ...... 118 2 3 Summary of key themes from semistructured interviews on life problems, resources and social stratification by ethnographic community. ....................... 11 9 3 1 Purposive lif e stage sampling a . ................................ ................................ ........ 140 3 2 Free list of life priorities. ................................ ................................ ................... 140 3 3 Cultural consensus key of life priorities. ................................ ........................... 141 3 4 Rank of problems and sources of social support. ................................ ............. 142 4 1 Descriptive statistics of study sample. ................................ .............................. 171 4 2 Multivariable linear regression of inverted systo lic blood pressure (1 / SBP) on socioeconomic status (SES), cultural consonance in life priorities (CCLP), interaction terms and covariates. ................................ ................................ ...... 172 4 3 Multivariable linear regression of inverted diastolic blood pressure (1 / DBP) on socioeconomic status (SES), cultural consonance in life priorities (CCLP), interaction terms and covariates. ................................ ................................ ...... 172 5 1 Cultural model of lifestyle. ................................ ................................ ................ 192 5 2 Means (Â±SD) or percentages for major variables, for total sample (N = 100) and by sampling cluster (n = 25) a . ................................ ................................ .... 193 5 3 Multivariable linear regression of cultural consonance in lifestyle (CCLS), subjective socioeconomic status (SSS) and covariates on inverted blood pressure (1/SBP and 1/DBP) and square root of depressive symptoms. ......... 194 5 4 Multivariable linear regression of standard socioeconomic status (SES), subjective socioeconomic status (SSS) and covariates on inverted blood pressure (1/SB P and 1/DBP) and square root of depressive symptoms. ......... 194
10 LIST OF FIGURES Figure page 1 1 Typical chronic stress process model without explicit specification of culture. ... 84 2 1 in JosÃ© BalliviÃ¡n province, Beni department, Bolivia. ................................ ................................ .......................... 114 2 2 Consensus ranking of sources of social support for the top ten life problems ( N =69). ................................ ................................ ................................ ............. 115 2 3 Map of Aj Ã ethnographic research community in JosÃ© BalliviÃ¡n province, Beni department, Bolivia. Households are indicated by orange circles and sized by number of household members. ................................ ................................ ....... 116 2 4 Map of Serrucho ethnographic research community in JosÃ© BalliviÃ¡n province, Beni department , Bolivia. Households are indicated by orange circles and sized by number of household members. ................................ ....... 117 3 1 Location of the two ethnographic study communities and nearest major market towns. ................................ ................................ ................................ ... 134 3 2 The photo of a ladder and corresponding scale used to exp lain ratings exercise options for evaluation of items in the domain of life priorities. The text reads, 1 ..... 135 3 3 Alan Schultz. 2012. Examples of the photo cards used to identify sources of intentionally omitted), D) Community leaders, E) Medic al doctors and F). ....... 136 3 4 Scatterplot of loadings for the model of life priorities colored by AjÃ (accessible community in red) and Serrucho (remote community in blue; markers sized by age; bars are 95% confidence intervals). ............................. 137 3 5 Scatterplot of loadings for the model of social support colored by AjÃ (accessible community in red) and Serrucho (remote community in blue; markers size d by age; bars are 95% confidence intervals). ............................. 138 3 6 Deviation in community average item ratings |0.53| to |2.28| for the domain of life priorities (x axis: accessible community, AjÃ; y axis: remote community, 139 4 1 Location of the eight epidemiologic survey communities (including the two ethnographic communities) and nearest major market towns. ......................... 164 4 2 Histogram of socioeconomic status distribution in the study sample. ............... 165
11 4 3 Locally weighted scatterplot smoothing (Lowess) curve regression of the bivariate relationship between systolic blood pressure and cultural consonance in life priorities (two outliers not pictured). ................................ .... 166 4 4 Association between age and systolic blood pressure (1 SD=15.25mm Hg; p<0.0 5; bars represent 95% CI) stratified by gender and adjusted for pregnancy status and body mass (note: y axis values of blood pressure are .. 167 4 5 Average community consonance in life priorities for each item tested, limited to and stratified by the accessible ( AjÃ ) and remote (Serrucho) communities [*scores based on respondent recall of previous month except where ............. 168 4 6 Interaction between socioeconomic status (SES) and cultural consonance in life priorities associated with systolic bloo d pressure (1 SD=15.25mm Hg; p<0.05; bars represent 95% CI) adjusted for age, sex, pregnancy status and. 169 4 7 Interaction bet ween socioeconomic status (SES) and cultural consonance in life priorities associated with diastolic blood pressure (1 SD=9.32mm Hg; p<0.05; bars represent 95% CI) adjusted for age, sex, pregnancy status and. 170 5 1 Interaction of high (>5; n =66) and low (<6; n =34) subjective socioeconomic status (SSS) and cultural consonance in lifestyle associated with systolic blood pressure and controlled for age, sex, BMI, and antihypertensive ........... 190 5 2 Square root of depressive symptoms (CES D) regressed on cultural consonance in lifestyle controlled for age, sex, BMI and SSS (bars are 95% confidence intervals). ................................ ................................ ........................ 191
12 LIST OF ABBREVIATIONS BMI Body mass i ndex ( weight kg / (height m) 2 ) CCA Cultural consensus a nalysis CCLP Cultural consonance in life p riorities CCLS Cultural consonance in l ifestyle CCM Cultural consensus m odel CCT Cultural consensus t heory CES D Center for E pidemiol ogic Studies Depression S cale DBP Diastolic blood p ressure GCT NTM New Tribes Mission PPI Per person income (household income / total number of household members) PPW Per person wealth (household wealth / total number of household members) SBP Systolic blood p ressure SES Socioeconomic s tatus SSS Subjective socioeconomic s tatus
13 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy BIOCULTURAL ANALYSES OF SOCIAL STATUS, CULTURAL MEANING, AND HORTICULTURALISTS IN LOWLAND BOLIVIA AND URBAN PUERTO RICANS By Alan Frank Schultz August 2014 Chair: Clarence C. Gravlee M ajor: Anthropology In this dissertation I analyze sociocultural data from a geographically diverse sample of forager horticulturalists in Bolivian Amazonia and urban Puerto Ricans with three main aims : ( 1) to integrate long term participant observation with structured ethnographic methods to explore whether the meaning of social status varies due to market exposure , ( 2) to describe consensus and variation in cultural models of life priorities and social supp ort due to market exposure, and ( 3 ) to test whether shared cultural models are ass ociated with chronic stress related health outcomes. In the first study I explore semistructured interviews in an accessible vers us remote community . I find that decreasing socially focused life priorities, increasing loss of control and increasing exposure to discrimination all have a major influence on the meaning of a good life and the options people have for dealing with change. In the second study I analyze rankings and ratings exercises to test for shared cultural models of life priorities and social support. I fi nd moderate to high sharing in both domains but systematic variation in residual agree ment along second ary factors . R espondents from the remote community have
14 several unique preferences tied to long In the third study communities. I find t hat consonance in life priorities buffers against high blood pressure . I also find that socioeconomic status moderates the association between consonance and blood pressure so that those with high socioeconomic status have significantly higher blood pressures when their consonance and socioeconomic status are incongruous . In the final study , I evaluate data on health outcomes and cultural consonance in lifestyle among urban Puerto Ricans and find that subjective socioeconomic status moderates t he relationships between consonance and systolic blood pressure. Separately, I also find that consonance is associated with fewer depressive symptoms. I conclude that incongruous levels of cultural consonance for those with high status are correlated to hi gher systolic blood pressure and worse mental health likely due to the psychosocial stress of status anxiety. This dissertation integrates analysis of ethnographic and epidemiologic data from a unique forager horticulturalist population and urban Puerto Ri cans to add to the body of evidence linking the meaning of social status and social support to chronic stress and health. Furthermore, it suggests new directions for sociocultural research on stress.
15 CHAPTER 1 INTRODUCTION It is strange Indians who do n ot have the slightest interest to adorn themselves. We never see someone who has painted or tattooed himself. The women have some simple necklaces of seeds and glass beads. The children wear some necklaces of seeds and teeth. The older men seem to despise all that. Swedish archaeologist Erla nd NordenskiÃ¶ld on the lack of conspicuous in 1908 (1915 Overview C ulture change in a context of in situ market exposure leads to a consistent positive association between social status and health that obtains even when absolute material resources are accounted for (Marmot and Wilkinson 2001). Often referred to as the social gradient due to increasingly detrimental health effects amon g those located each rung lower on the social ladder , this association and its effect size are not universal in all types of human or even primate societies ( McDade and Nyberg 2010 ; Sapolsky 2004 ) . Specifically, the social gradient seems to have a less int ense effect on population health when labor, capital, land, and goods and services are not fully commoditized such as in forager, pastoral, and horticultural societies (Lu 2007:593; Waldron et al. 1982 ) . The sources of variation in the severity of social gradients between market societies, however, are less clear. W hile we know that gradients measured using wealth or income are plastic a n d vary from society to society, the difficulty of st udying most non market settings has limited work on the symbolic mec hanisms underlying inequality when the influence of markets is small or absent (Dressler 2010; McDade and Nyberg 2010 , Chin Hong and McGarvey 1996 ) . Better understanding of the nature and extent of such variance in health will help to clarify whether the i nequality that accompanies market integrated
16 societies is qualitatively different to the social gradients of non market societies or quantitatively so. In so doing , it will also help to better characterize social status mechanisms and may even shed light on how to determine what stressors and resistance resources can best improve health in various market and non market settings (Dressler 2010 ) . The study of meaning in social gradients has been hampered by past difficulties with measurement. From an analysis point of view this is partly because culture can be highly variable from group to group and is often assessed qualitatively at the group unit of analysis. None the less, culture is crucial to determining what it means to occupy a high social pos ition in any particular setting and cannot be assumed to be unimportant at the individual unit of analysis unless shown otherwise (Dressler 2010; Townsend 1988 ) . Put more directly , m eaning is an important cultural determinant of health that requires explicit measurement. The central goal of this dissertation research is to help solve the puzzle of why market integration leads to the development of severe social gradients b y investigating the cultural meaning of status through its explic it measurement in two groups at very different stages of integration. The first group is horticu lturalists who live in Bolivian Amazonia and as a group are only minimally integrated into the market economy . The other is an economically div erse sample of urban Puerto Ricans from the southern municipality of Guayama w ho se society is already highly integrated into the market economy . The foundation of my work is a mixed methods approach based on participant observation, empirical measurement of culture, and epidemiologic surveys, which when
17 combined allow me to build upon and triangulate successive findings to strengthen results. The work culminates in epidemiologic surveys that allow me to systematically test the signif icance of symbolic status roles on health at the individual unit of analysis . In this way, I aim to add to , and improve on universal measures of status that have become standard social determinants of health , namely socioeconomic status (SES) . I do this us ing the cultura l consonance measurement model articulated by William Dressler (Dressler et al. 2005) . Cultural consonance is defined as the degree to which individuals in their own beliefs and behaviors approximate the culturally valued conception of a goo d life encoded in the dominant cultural model ( see below; Dres sler and Bindon 2000) . It better accounts for the nuance and meaning of status from place to place and can therefore be used for more valid cross cultural assessments and commensurable measurements (Dressler et al. 2005) . I leverage cultural consonance to compare the impact of meaning on status, psychosocial stress and health in two settings and groups with very different life priorities and levels of market exposure . The first is the who are especially well suited to studying the meaning of status not just because of their minimal market integration and the stark comparison it provides to industrial societies but also because of what we already know about this group. D espite over two decades of increasing market exposure they possess extraordinary cardiovascular health profiles virtually free from chronic psychosocial stress biomarkers and related disease (Gurven et al. 2009; Gurven et al. 20 1 2). In fact, base d on short term biomarkers they have some of the lowest mean stress levels ever reported (Nyberg 2009 ; Nyberg 2012 ) . Both of these outcomes are the opposite of what is typically found in groups undergoing market integration . It indicates that the
18 differences in the , compared to what is found in market integrated settings , are more than ju st novelties to be catalogued but something to be studied and understood as a potential source of new insight . Their culture and society potentially hold clues t o some of the critical questions about human health and society such as why we have a tendency to conform to the needs and ideals of a group , why some people so ambitiously seek out high status role s , and how to balance personal freedoms with the need to c onnect with others (Cacioppo and Patrick 2008) . P social status and health also confounds conventional w isdom about culture change, market exposure and health. For example, higher social rank in this group has been associated w ith better anthropometric measures but only when a standard measure of SES is controlled out and in the absence of local ly appropriate psychosocial stress measures (Reyes Garcia et al. 2008). Without a contextual understanding of stress, such findings lack explana tory power and may prove false. I try to unravel some of the mystery surrounding how the health by considering the role of status in the psychosocial stress pathway from a biocultural persp ective. Psychosocial stress is a widely investigated link between inequality and poor health that has been shown to work at a physiological level by causing an imbalance in the hypothalamic pituitary adrenal (HPA) axis, among other psychosomatic mechanisms ( see below for a more detailed discussion of the physiology of stress; Kaplan 1983 ; Marmot 2002) . A well established if imprecise proxy for detectin g th ese effects is blood pressure. I test for associations between psychosocial stress outcomes and culture among both a sample of
19 individual approximations to local cultural models (i.e. cultural consona nce), SES , and covariates against blood pressure and other health outcomes . Psychosocial stress is usually conceptualized as a process ( see Figure 1 1 ). In this process , buffers play an important role in attenuating chronic responses to stressors including social support. have a unique form of social organization compared to pe ople in most market societies and therefore potentially higher levels of social support (Daillant 2003) . Research demonstrates that the social configurations found in mar ket economies are distinct from those that existed during most of human evolution and that these differences often including a reduced level of social support in market integrated settings are linked to chronic stress (A rmelagos et al. 2005; Sapolsky 2004; Wilkinson and Pickett 2007 ) . A focus on culture in the stress process is therefore important because when culture changes along with market exposure the balance between stresso rs an d resources can shift dramatically (McDade and Nyberg 2010). My approach is based on r ecent theoretical and measurement advances in biocultural medical anthropology that improve our understanding of the psychosocial stress process. This work expands on typical stress process models that are firmly rooted in social epidemiology such as the example model of the chronic stress process in Figure 1 1 (adapted by the author from similar model s originally developed by Pearlin et al. 1981 an d more recently by Ice and James 2007 ). In these arrangement s and others such as Nancy heuristic d iagram of Ecosocial Theory (2008 ) , social epidemiologists explicitly conceptualize the social determinants of health while failing to acknowledge an y explicit role for culture in psychosocial stress or inequality . That is,
20 c ulture appears neither as stressor or buffer in their work . Instead, it is either completely missing or in the case of Krieger seemingly subsumed as part of the societal or ecosystem levels of area, group, region and so on . In contrast, c ultural consonance can be characterized as an explicit measurement of the cultural determinants of health. C ultural consonance is built on the precepts of cultural consensus theory ( outlined below) . It assesses individual approximati ons to models of culture whose exact level of sharing have been quantified and verified ( Romney et al. 1986; Dressler 2005 ) . Just as with the best measure s of the social determinants of health, cultural consonance can be collected and assessed at the individual unit of analysis against stress biomark er s and related health outcomes. This allows for the test ing of hypotheses about psychosocial stress and other pathways of inequality . Unlike most measure ment s of socia l determinants, however, cultural consonance explicitly incorporates local meaning. Cultural consonance builds on cultural consensus theory, which allows researchers to test the differential sharing and enactment of cultural models (Romney et al. 1986). C ultural consensus theory assumes that culture exists in the mind and provides a testable framework for its measurement. This allows similarity of belief to be evaluated without imposing a priori assumptions. The model does require some assumptions, however , including that correspondence between individuals is a function 1987). In order for the model to be valid, ( 1) informants selected for evaluation must also be independe ntly chosen from a common culture, ( 2) the domain investigated must ( 3) answers from informants must be
21 provided independently from other informants and, ( 4) questions must all be of equal difficulty to answer (Romney et al. 1986). Through its use of cultural consensus modeling, the cultural consonance measurement model ultimately relies on a cognitive theory of culture to theo retically ground its approach. Cognitive anthropology describes culture as a body of k nowledge that is differentially shared between individuals (Goodenough 199 1984). Knowledge itself is understood as roadmaps of how the world works ( Shore 1998) . These maps overlap and are socially transmitted but remain flexible. C onceptual fr ameworks of schemata and cultural models further detail how bodies of knowledge are differentially shared and acted on (St rauss and Quinn 1997; 1995). Importantly, modeling connects this theory to research through the systematic measurement of in dividual level knowledge that can then be aggregated and analyzed to identify shared bodies of knowledge. In the biocultural study of health, measurement of how bodies of knowledge are differentially composed and enacted in social groups is crucial because it allows researchers to pinpoint the most important local cultural domains that affect health and well being t hose that mean more than others. R esearch f indings have demonstrate d a common interaction between SES and cultural consonance with higher levels of consonance moderating against the effects of stressors on health (Dressler 2007a; Dressler 2012; Panter Brick and Fuentes 2009). Such a role for SES may be explained by it functioning as a component, but not the totality, of relative social stat us. As just one part of a more broadly conceived social status, the impact of SES on health can vary as a function of its importance locally. W ith cultural consonance , however, material components are weighted against a broader set
22 of empirical items as ge nerated, ranked and verified among members of the local culture during cultural consensus modeling (see design and methods below for more details on consonance measurement ) . Social epidemiologists Kawachi and Kennedy (1999) have even recommended cultural c onsonance be investigated as a mediator of the effect of the scale of economic inequality. Their intuition is that status may widely be tied to cultural meaning and its measurement could therefore improve work to understand the origins and functioning of i nequality . , whose status is not strongly t ied to income and wealth , the idea that cultural meaning regarding the priorities in life would be central to status , seems an obvious one. Despite their isolated location and limited market access , the have been the subject of an outsized number of health s urveys over the last 25 years. They have also been increasingly exposed to other Bolivian and foreign groups over the last few decades as they make more trips o ut of their territory and others make more incursions into it . R ecently , have even begun to play a more central role in regional and national politics. To capture this process , I expand ed the ethnographic purview of my research beyond just the loc al. I did this to try to understand the political economic place in Bolivian society and history , a theme that has otherwise been neglected co mpared to other research on this group . I found that d ecisions on how the market economy integr are being negotiated in a complex milieu mostly that they often hinge on the whims of just a few powerful actors. Therefore , I include an account of politic al economic factors over time below as well as in parts of the manuscripts .
23 This aids me in explain ing observed patterns of emergent marke t integration among this group. Finally, the data from Puerto Rico represents a compelling juxtaposition in setting and culture to lowland Bolivia and t In collecting the data, Gravlee used a similar measurement approach in the southern Guayama municipality (Gravlee et al. 2005) . The participants in the survey were all city dwellers who relied almost exclusively on wage and salary to fulfill t heir needs. As expected, the cultural data provide a stark contrast in content to wha the idea of a good life is constructed from largely unique or differently prioritized cultural items ( e.g. a top rated item for clean water while refrigerators are important in Puerto Rico but not mentioned in Bolivia ). Still, despite these distinctions in content, the nature of the relationship between cultural consonance and health outcomes in both samples is remarkably similar. Whether among a group of forager horticulturalists or Puerto Rican urbanites, there appears to be important benefits to health for those who best approximate the shared cultural domains of the people around them even when the contex t and social setting of those domains are otherwise quite dissimilar . The Research Project My dissertation research began with a pilot project I coordinated around my participation in the National Science Foundation (NSF) cultural anthropology field schoo l run by Ricardo Godoy, Victoria Reyes Gar cÃa, TomÃ¡s Huanca and the Amazonia Panel Study (TAPS) team from J une to August 2010 in Bolivia. My project focused on mapping and analysis of personal and whole social networks among applicable to the work presented here was my w hole network analysis on data I collected from every head of
24 community. This alter data (an alter is an acquaintance named by a survey participant during a social network elicitat ion who matches any number of specified criteria) was limited to those community members who were peer nominated as relatively highly market integrated. Though restricted to just one community, who took part had approximately average access to the market compared to those living across all other communities . This resulted in sufficient local variation to provide useful insight . The results suggested that there was something qualitatively different about the status of people whose peers perceived them as highly engaged in market activities. In particular, those with the most peer nominations for strong market integration were less ce ntrally located in the whole network of market alters . In the coming chapters much of my analysis touches on questions raised by my pilot project including: (1) What is the Is market inte gration inversely related to local conceptions of status as indicated in the pilot? And, (3) Why have changes in shared conceptions of status not yet occurred or resulted in severe social gradients despite over twenty years of in situ market exposure? to the study of change, psychosocial stress and society. A key advantage is that past researchers have collected strong evidence for a consistent inverse relation ship between market integration and geographic distance to market towns for individual T his consistent relationship has been used as a proxy for integration to better account for its effects on various factors related to health, which I
25 review below. Despite community variation in levels of integration, however, data on the , on average, has some of the best chronic stress related disease outcomes and short te rm stress levels in the world o ut comes that typical ly worsen during rapid change. yet to be significantly impacted by the severe social gradients so common in market ce resources that buffer against chronic stress related outcomes. I expand on this body of knowledge by building and verifying empirical models of stress related cultural domains including life priorities and social support, based on participant observatio n and structured methods. This allows me to study novel aspects of meaning and status to help evaluate whether case (a) or (b) might be more plausible. I first investigate th e processes involved in shifts of the balance between psychosocial stressors and r esistance resources in Chapters 2 and 3 through a 20 minute bus ride from the nearest market town) and a remote community, Serrucho ( also a pseudonym; a 10 hour motorized ca noe ride, in good weather, from the nearest market town). An additional advantage of working with a small scale society like that of determining life priorities. That i s, the re spondents I talked to only live around other , which eliminates confusion about whose life priorities they are talking about when responding to questions . I can also take advantage of the comparative perspective gained by studying a settin g where three fourths of people maintain especially close traditional kin connections that are distinct from tho se in industrial
26 societies (Undurraga et al. 2010). Such dense networks can be expected to offer more support for those who need it ( Cacioppo an d Patrick 2008; Maybury Lewis 2009 ) . I use this data to empirically test questions about societal makeup, relative status and meaning by looking at associations between consonance and health outcomes Chapters 4 an 5, respectively . In t I analyze data from an eight community N =209). Table 1 1 lists basic summary statistics from the epidemiologic survey including subsamples from the two ethnographic stud y communities. The Puerto Rico consonance study is based on an epidemiologic survey ( N =100) collected among four economically distinct neighborhoods in southeastern Puerto Rico by Clarence C. Gravlee in 2001 (Gravlee et al. 2005). Sum mary statistics are in Table 5 2 . The studies described here add to ethnography and qualitative research on health and meaning including exploratory analyse s of ties between rapid change, life challenges, resistance resources and social stratification . More broadly, by isolatin g the roles culture and meaning have played in determining social status and potentially preventing chronic stress during the early stages of market exposure , my work suggest s new lines of inquiry for market populations with high levels of chronic stress. The three main aims of the research are: 1. to integrate long term participant observation with structured ethnographic methods of social stratification 2. to describe consensus and variation in cultural models of life priorities and social support due to market exposure
27 3. to test whether the fit between individual behavior and shared cultural models is ass ociated with health outcomes in an industrial Caribbean society versus a n on industrial Amazonia society In the remainder of this introduction I first present my overall study design and methods. This is followed by an ethnographic vignette on the place and history of the nomy of Bolivian society. Lastly, I conclude with a literature review on topics related to my research . I cover several streams of literature to which my work contributes including (1) Social Status, the Stress Process and H ealth , (2) C ulture Change, Market Integration and Psychosocial Stress , (3) Biological Anthropology and Adaptation Theory, (4) The Mean ing of Inequality in Non Industrial Society, (5 ) Market Integration and Indigenous Health, (5) Bolivian Policy and Indigenous Health, (6) Health and Well ) Research Design and Methods Participant Observation a nd Ethnographic Data Collection This first and most substantial phase of the project was the et hnography that covered topics not previously addressed by other studies . TAPS researchers provide d introductions to communities and gave critical counsel on establishing and maintaining good local relations . The foci of the ethnographic phase were : (1) to describe the distribution of cultural knowledge about what makes life meaningful for Tsimane' from two villages that vary in their level of integration to Bolivian society and the market economy, (2) to elicit perceptions on changes taking place in the com munities as a result of increasing market expos ure, and (3 ) to collect cultural consensus data. Language training . My initial language training began on site from June August 2010 with an additional seven non consecutive months of tutoring between July 20 11
28 the language outside of lowland Bolivia. My instructors were and teachers in San Borja, Bolivia . Tsim language ability was an important part of my particip ant observation in the villages. It allowed me to establish rapport and to learn how to act so that residents could continue with their lives as normally as possible (Bernard and Ryan 2011 ). For comparison, under similar constraints the Amerindian ethnographer David Maybury Lewis spent eight months in on site immersive language study before starting his dissertation research with the Xavante , a similarly isolated group at the time (Prins an d Grahm 2008 ). Field assistant . TAPS researchers assist ed me in the villages and administer ethnographic interviews and epidemiologic survey s. During the course of the research I employed two different native translators, each for about seven months each . They assisted me with day to day tasks, administration of interview s and surveys and with gaining entrÃ©e and building report with community members. Long term participant observation . After completing several months of language training in and out of the villages , I took up residence in AjÃ (2 0 minutes from the market town of Yucumo by motorcycle) and Serrucho ( one two days upriver by motorize d canoe). My typical stay varied from three to seven weeks at a time in each village before needing to resupply and switch to the other village . The benefit to this strategy came from being able to iteratively build an on the ground comparison of
29 similari ties and differences in local perspectives between the two settings regarding social status, social relations and material lifestyle. It also help ed to prevent historical threats to validity due to the ongoing process of building rapport and improving my T demands (e.g. farming) during the year. Participant observation was my exclusive method of data collection for several months before I began to conduct semi structured interviews , structured interviews and the epidemiologic survey . A key task as participant observer was to make a systematic record of day to day interactions, behaviors, and conversations by writing daily field notes. I tried to pay tion, ways of being and culture change. While living full time in the villages I participate d in mundane subsiste nce activities (e.g . communal fishing, tending agriculture, visiting San Borja) an d in everyday social life (e.g. sobaqui , or casual visiting; communal gatherings; movie night around the village television). Participant observation allowed me to investigate and describe the local political and administrative framework, impact of past research, community structure, ontology, and socio economic organization, all of which situate d the different models of cultural consensus I later investigated . Semi structured interviews . I conduc t ed s emi structured, open ended interviews in each of the two ethnographic study communities. The purpose of these interviews was to understand Tsimane' perceptions of (1) what makes life meaningful and satisfying, (2) the changes taking place in their comm unities because of market exposure, and (3) local perspectives on the differences between Tsimane' and between
30 were selected using a purposive quota sampling design. The goal was to maximize variation in individual att ributes and life experiences related to market exposure. S ample size was based on expectations from theory (Romney et al. 1986) and empirical research (Guest et al. 2006), which suggest that 8 12 individuals are sufficient to capture salient themes in cult ural domains with a modest level of agreement among informants. This sampling strategy allow s for meaningful comparisons across major sampling strata (e.g. age, gender, and cash income as a proxy for market integration ). I took notes and record ed audio dur ing interviews then wro te up expanded field notes on the day of the interview. Analysis focus ed on the expanded field notes to allow incorporation of observations and context into the data. I identified themes and constructs that cut across the data using methods identified by Ryan and Bernard (2003) and made comparisons within and between groups of informants u sing standard statistical (e.g. chi square tests for occurrence of themes between groups) and visualization methods (multidimensional scaling of co occurrence of themes within interviews). Free listing . I used a free listing exercise to systematically identify the people and material i tems that are associated with a good life . The precise phrasing of my free list question varied from past researchers who have asked about how to live a good life ( my emphasis; Reyes Garcia et al. 2010) . Instead, I asked , l of the things and people you need to live a good life here in the The subtle difference of specifying place instead of was important because there is a
31 the name of the old way of living. I collected the free lists using the sampling strategy described above for the semi structured interviews . I record ed responses verbatim and analyze d the aggregate frequency, rank, and salience of items to identify the contents and boundaries of t he cultural domain (Borgatti 1998). Protection of Human Subjects . When I invited community members to participate in my study, I verbally review ed a statement of informed consent with them in their native language . I explain ed the purpose of the study, the kind of data that would be collected, and the strict confidentiality that would be maintain ed for all conversations and data. I emphasize d that participants had the right to withdraw from the study and to refuse to answer any question, at any time, for any reason, without repercussion. No data collection proceed ed until all concerns were addressed and participants agree d to their role in the study. Due to high illiteracy rates , and with IRB and local approval, verbal agreement serve d as consent (per Common Rule 45 CFR 46.116.d, 117.c.1). Data Analysis: Interviews I began a nalysis of semistructured interviews with a review of interview notes, followed by a systematic anal ysis of interview transcripts. I identified important them es using both inductive and deductive approach es (Ryan and Bernard 2003). I also constructed a codebook according to the guidelines recommended by MacQueen et al. (1998). MAXQDA text management software (VERBI GmbH, Berlin, Germany) facilitate d the analysi s. I focus ed on the relationships among structural (based on questions) and interpretive themes as well as the distribution of themes a cross informants ( Strauss and Quinn 199 7). I also used s tandard univariate numerical and graphical summaries to assess th e range, central tendency and distribution o f themes.
32 Bivariate tests (e.g. chi square) helped me to evaluate the distribution of themes across categories of age, gender, and market integration. I then used the relationship between themes to develop hypoth eses that were tested in the structured interviews. Structured interviews: ratings and rankings . Based on free list results, I identified 38 items related to ideal Tsimane' life priorities and ask ed new samples of informants to rate them in terms of their importance for a good life in the community . I limited the number of highly ranked items included in the exercises and found that h igh salience items were rated as important to the preferred Tsimane ' way of life. The remaining items were drawn from low salience free list items and from participant observation and interviews. The balance between high and low salience items is necessary to minimize response bias, which threatens the validity of cultur al consensus analysis (Weller 2007). To collect ratings, I showed informants a drawing of a ladder I then ask ed informants to place each item on the ladder. TAPS researchers have used this technique to collect other types of ratings in the ir panel study and found that the Tsimane' understand it well , which matches my experience . Rankings exercises were constructed based on quantitative analysis and qualitative emphasis of im portant sources of support and critical life problems identified by respondents in the semistructured interviews. In total 10 problems and 5 possible sources of support were identified and tested for salience based on a rank of most, second most and third most important. Additional details on calculation of the ranking scores are included in Chapter 3.
33 Data Collection: Epidemiologic Survey Sampling . The survey include d a sample of 209 adults (aged 15 75 ). I determined an ideal sample size of 200 through a series of power analyses for multiple regression to test hypotheses about the health effects of (1) market exposure, (2) cultural consonance, (3) life events, (4) discrimination, and (5) coping resources. The power analyses assumed power (ÃŸ) of 0.80, a B onferroni regression model with eight predictor variables, and a modest correlation among predictor variables (r=.40). Based on previous research using similar methods, I 2 = .03 .05, comparing full to reduced models excluding income/wealth, market exposure and consonance . The results of power analysis suggest ed that a sample size of 150 240 participants would achieve sufficient power to detect relatively small effect sizes. The ac hieved sample size of 209 balances research objectives with the practical difficulties of collecting the data . S ampling frame s for the epidemiologic survey were based on a full listing of all households present during the interview period and participants were randomized locally using a community wide lottery . Measurement of Dependent Variables . Stress is notoriously difficult to define and measure, therefore studies must disentangle cause from process an d outcome (Chrousos 1998). stress process model based on consonance includes three categories of consequences of stress exposure: a) physiological reactivity, b) mental health, and c) health related behaviors (Dressler 2007a). Below, I describe how the dependent variables in each of these categories were measured. (a) Hair Cortisol and Blood Pressure. I collect ed 25 mg samples of hair of at least 2 cm from the posterior
34 vertex part of the scalp using fine scissors following the protocol previously outlined by Kirschbaum et al. (2009). Each of these samples was then cut into 2cm long segments for analysis to determine retrospective mean systemic cortisol levels . The results of these analyses are still pending and will be published apart from this di ssertation. The encountered no problems collecting samples. The samples were stored dry and occasionally transported to San Borja for safe keeping at the TAPS office until shipment for analys is. I expect hair cortisol levels, as retrospective records of average chronic stress, to be inversely associated with cultural consonance. Measurements of blood pressure were taken using an automatic blood pressure monitor, Omron Model HEM 705CP. This mod el has been validated for use in population based studies by the British Hypertension Society, 1996). Three readings of systolic and diastolic blood pressure were recorde d at standardized intervals following ten minutes of inactivity and the first measure ment s were dropped to eliminate the risk of researcher induced hypertension . Statistical analyses were based on the average of the second and third readings. Blood pressur e, as a less precise indicator of chronic stress, was expected to be inversely, though more weakly, associated with cultural consonance. Mental health (b) and behaviors (c). These measures ca me from self report and were collected based on piloting of protocols used by TAPS. Q uestions were based on validated instruments and qualitative data then adapted during pilot testing . I expect ed that psychological well being would be indicated negatively by self reports of perceive d stress and depressive symptoms and positively by self reported overall health and mental health (Reyes -
35 Garcia et al. 2010). Measure ment s of health behavioral consequences of stress include d commercial alcohol consumption , coca use and cigarette use (Dres sler 2007a). Stress behaviors were expected to be inversely associated with consonance. Measurement of cultural consonance . Dressler et al. (2005) describe a procedure for measuring cultural consonance in lifestyle and social support that I followed . In t he exploratory phase, I described the cultural models relevant to these domains and obtained consensus estimates on how items in each domain rate d along dimensions that were meaningful to participants. In the survey phase, I collect ed data own self reported behavior in these domains. For life priorities , I ask ed respondents whether they own the items or participate in the activities identified as important in the consensus model. For social support, I ask ed about the types and sources of sup port. Cultural consonance was then calculated as the degree to which lf reported behavior corresponded to the prototypical behaviors encoded in the cultural models. Measurement of Market Exposure . Market exposure was measured through proxy v ariables including distance from the nearest market town (either Yucumo or San Borja ) , income and wealth . Unlike previous studies in the region, I calculate distance to the market using two reference towns since respondents report ed making visits to Yucumo at least as frequently as to San Borja and of preferring visits to Yucumo . Measurement of Covariates . The covariates measured include d standard sociodemographic variables commonly used in stress research: age, sex, socioeconomic status (ba sed on a principal components analysis of per person income and per person wealth) , marital status, height, weight, BMI , pharmaceutical intake,
36 alcohol consumption, and smoking behavior. The calculation of income and wealth is described in detail in Chapte r 4. Measurements of age, sex, marital status, and medicine and tobacco consumption were ascertained during interviews. Height was measured in centimeters using a 214 Road Rod Portable Stadiometer, and weight measured in kilograms using a Tanita Body Compo sition Analyzer/Scale, Model BF 350. These measure ment s were used to calculate body mass index (BMI). Waist to hip ratio was measured using anthropometric tape. Nutritional data and dietary habits were not collected due to the excessive cost and time requi red for valid and reliable data. Data Analysis: Epidemiologic Survey Initial exploratory analyses bega n with descriptive statistics and graphical displays of data, in order to identify potential violations of assumptions regarding normality, constant variance, and linearity (Tukey 1977). To examine the dependent variables (blood pressure, psychological out comes), I ran a series of multiple regression models ( see Chapter 4 ). For each dependent variable, I enter ed sets of variables in steps: the standard covariates (age, sex, BMI, education, income), followed by key independent variables and cultural consonan ce. organization and interaction with Bolivian and international societies as well as federal and regio nal governments helps to frame the change that has already occurred and the likely possibilities for the future. In April 2010 a new municipal mayor, Jorge AÃ±ez Claros, was elected in San Borja , a frontier town located in the lowland tropical state of Beni in north central Bolivia that has leading exports of cattle, crops and a dwindling supply of tropical hardwoods . The election was run without any significant reports of fraud but members of the former inc
37 complained to me a few months later that the result was sur prising, and possibly corrupt. The accusations did not involve il legality, however, but perceptions of unfairness in how the new mayor and his supporters from the Movement for Social ism (Movimiento Al Socialismo; MAS) party had bussed in geographically isolated supporters thereby altering the expected election dynamics. The 2010 San Borja election was a resounding triumph for AÃ±ez who had methodically shored up his support by convinc ing fellow to vote en masse for one of their own for the first time. Mr. AÃ±ez also garnered the endorsement of the first indigenous Bolivi an president, Evo Morales (MAS) a member of the Aymara people , who had just been reelected in 2009. The muni cipal incumbents in San Borja had likely underestimated the true size and strength of the MAS supporters, especially considering the free transportation and uncommonly large turnout other indigenous supporters . Indeed, in the eleven y ears between the last two JosÃ© BalliviÃ¡n province grew on paper at least by 244 % (from 3,614 to 12,442) while the total provincial population increased just 20 % (from 66,304 to 80,121; INE 2014 ). Curren tly , indigenous groups represent 42 % (33,868) of all residents there ( INE 2014 ). AÃ±ez is not just the first e . This was not the first time AÃ±ez set a new . of New Tribes Mission (NTM) an American Evangelical group with missions throughout the world and a U.S. headquarters in Sanford, FL. There had been teachers bef ore Jorge but he was the indigenous face of NTM even appearing in their
38 promotional literature ( NTM 1986 ; 1994 ). To this day, Mayor AÃ±ez located outside o f town but just next door to the NTM Horeb Training Center. The story of Jorge AÃ± ez changes happening in JosÃ© BalliviÃ¡n province where over a third of the indigenous years. During this time they have continued to live almost exclusively as self sufficient and market independent i.e. autarkic forager horticulturalists along the Maniqui river (Metraux 1942 ; Ringhofer 2010; Figure 2 1). Researchers have reported high levels of inter village mobility by T in the same area s (Daillant 2007; Ellis 1996). For example, t here has been enough constancy in the last century at least that some of the same communities visited and documented by Swedish arch aeologist Erland NordenskiÃ¶ld in 1908 remain intact today (1915 ). Recent changes have been driven by political economic events at both local and national levels. One of the most dramatic was a period of extensive logging by large outside companies that s tarted in the 1970s. It led to the removal of the vast majority of hardwood near the Maniqui, which resulted in loss of habitat for animals, flooding and land erosion near the river , and degradation of water quality that continues t oday (Daillant 1997; Tan ner 2005 currently happens at a reduced scale and rate with many of the work contracts now carried out by . Outside l ogging companies used to hold significant local political influence with GCT; . Since its creation in 1989
39 and eventual receipt of control over GCT has been under constant pressure from government and logging interests to deliver favorable contracts and land concessions ( Byron 2003 ). The Gran Consejo president for up until April 2010, not surprisingly, was also Jorge AÃ±ez H e used his platform as president there to build support f or his eventual municipal mayoral victory. In particular, near the end of his presidency AÃ±ez garnered support among his people by setting aside a ban on direct logging contracts between the GCT individuals . The ban had exclusively benefitte d outside logging companies by stopping the legally profiting off of the natural resources being extracted from their territory (Zycherman 2013). Just as Mayor AÃ±ez president and eve ntually mayor is interwoven with the history of Christian missionaries territory been spurred on by have long been known as a peaceful group but on e with a tendency to escape into the forest rather than confront colonists, loggers, missionaries and other outsiders and foes flourished here to the same extent as among several nearby lowland indigenous g roups (Huanca 2008; Metraux 1942 ). The largest Christian mission organization in the area is NTM, which started their work in JosÃ© BalliviÃ¡n in the 1940s and 1950s ( NTM 1986; 1990). The other mi ssions of note have been Catholic, though their history of missionizing is less broad, their contact possibly nearly 400 years (Bo lÃvar 1906; Metraux 1942 ).
40 Catholic missionaries also NTM built substantially more (Byron 2003 ; Ellis 1996; Huanca 2008). It was NTM who language that allowed for bilingual classes . This largess had dual purposes, one of which was to aid in teaching and the other was to produce a of the Bible (Ellis 1996). New Tribes Mission language news and religion radio station, Horeb, that has served as the sole form of territory wide communication for many years . Its usefulness is only now slowly being usurped by mobile phones as new cellular radio towers come online in the area . The treatment of neglect at best and passive exploitation at worst. In the 1970s and 1980s when massive logging operations broke the law and overreached, the government generally looked the other way. When Jorge AÃ±ez became a part of the nascent GCT in 1989 , NTM lent its support to the bid to establish GCT as the officially recognized governing body of the people. were quick to point out that Mayor AÃ±ez had not been the first choice of the pe ople to serve as president , though his was the successful bid. Not surprisingly, t his version of events remains contested. As Zycherman has previously observed , the creation of the GCT was accompanied by designation of community c o rregidores (local magist rates), a process that resulted in the first new distinct group s since NTM first trained teachers decades ago to run community schools (2013). Before these occupation and status linked roles emerged, the spiritually significant c cojsi (shaman) , most adults and others particularly skilled in valuable practices (such as hunting, fishing or farming) were those who commanded the
41 high est status. The best historical accounts tell us that the last fully trained c cojsi disappeared som etime in the 1980s taking with them much of the cultural knowledge and practice , including medicinal plant use (Huanca 2008) . c cojsi potentially related twist , many are now involved with NTM justified cosmology by citing its lack of cogency compared to Christianity . Meanwhile accounts of interactions between c cojsi nd past missionaries include tails of denouncement by both sides and even violence and murder (Huanca 2008). With the GCT in place, the regional government stepped in to assume responsibility for running community schools including training and assignment of teachers to communities in the territory during the early 2000s. This led to a reduced role for NTM and a shift towards a purely secular school curriculum. This shift has been accompanied by an improvement in the material quality of school facilities with a transition from wood to concrete and cinder block buildings . C hanges in the quality of instruction are more difficult to assess though most residents frequently expressed to me their displeasure with the current level of instruction . Today, many r ecently built schools in the territory bear the imprimatur of Mayor AÃ±ez including actual plaques with his name. For example, i n the community of Chara tÃ³n, where no running water or electricity exists as is the case in all but a couple ies , I was shown modern bathrooms with s howers only recently completed. The bathrooms had been locked up ever since, however, ostensibly until such time as running water became available . The community s informed me
42 that this was a very unlikely outcome and that there were no plans to deliver running water. To their minds the bathrooms were a waste of money since they would never be capable of their intended purpose . including the ministry that administer s school programs. Still, the most dramatic symbolic change of late is likely the federal requirement (as of 2011) that all local government employees speak or study one of the indigenous local languages common where they serve. In practice, this means many monolingual Spanish speaking non indigenous government employees in JosÃ© BalliviÃ¡n are now required to study the a requirement that would have been nearly impossible to enact just a couple of decad existed only as an oral language. Considered in an historical context, the nature of recent changes is quite significant. Almost one hundred years ago, Swedish archaeologist NordenskiÃ¶ld lamented what he feared later reflecting, Chimaneland is a beautiful country, inhabited by a people that would be worth a better fate than to become drunken servants to the Whites. Yet again, [the Whites] use brandy to wi n Indians over and abase them (1915 Subsequent 20 th Alcoholism became quite prevalent in part due to the practices of merchants and logging companies who took to offering wage advances in the form of cane alcohol to ory (Godoy 2001 ; Huanca 2008). The exploitative nature of this practice and its results has not always been well understood or acknowledged by those with influence among the people . The
43 light. created promotional litera ture to entice potential donors in the United States. In a NTM 1986). as understood by the missionaries including : disease, evil spirits, other tribal pe ople and natural phenomena (e.g. rainbows thought to foretell pending doom ). But there is one glaring omission to this li st of problems and fears, one that did not escape NordenskiÃ¶ld years before: incursions and exploitation by outsiders (1915) . Devoid of this spiritual, microbial and cultura l salvation and static in time . There is no mention of the threats from colonist incursions, exploitative river merchants, logging company concessions, destruction of hunting grounds , and the devaluing and discarding of native culture and native leaders li ke the c cojsi . Despite the ontological blind spot of NTM literature about the connections demonstrates different priorities . It is worth noting that the path followed by the former NTM teacher and pastor , Jorge AÃ±ez , has not always involved an explicitly Christian mission. Instead, after Mr. AÃ±ez assumed the presidency at the GCT he used his platform to consolidate power and eventual ly launch his successful regional political career in secular Bolivian society. Today he is currently
4 4 preparing for his second mayoral election in October 2014. Surely, t he choices and history of one man are not sufficient for making sense of rapid change among all but they do seem indicat ive of a sea change occurring. The patrons and exploiters of the recent past are now mostly acknowledged as such and often reje cted in their schemes. This includ es exploitative river merchants and logging companies who carry little trust with locals and are frequently told to move on. E ven municipal officials who seek community approval for state funded projects that never come to fruition are not highly favored . Community members believe the officials themselves pilfer the money once it is transferred for any particular project . The low rate of project completion does not help with this impression. Finally, a long with this new assertive stance , there are some emerging activists and leaders who talk about ending discrimination and gaining equal rights to health and education . Literature Review Social Status, the Stress Process and Health A widely tested theory posits tha t social hierarchies based on socioeconomic status result in a social gradient in health the higher your station in life, the better your health (Marmot et al. 1978 a ; 1991). The most commonly explored pathways for differences in health due to a social grad ient are the subjective status pathway of psychosocial stress and the objective neomaterial pathway of access to goods and services (Kaplan 1983; Lynch et al. 2001; Sweet 2010). Two of the most important lines of research that support the social gradient a re relative deprivation theory and epidemiologic studies of culture change. Relative deprivation theory originated with a sociological study, The American Soldier (Stouffer et al. 1949), based on the surprising finding that objectively better off
45 soldiers were not always subjectively better off. After examining what the objective measure ment s miss ed, researchers found 12 stressors and six moderating resources at play (cited in Lazarsfeld and Barton 1951: 160). Short and long term stressors (e.g. physical discomfort or loss of control) and many individual and social resources were recognized as simultaneously important for any soldier at war. These fresh insights came from detailed knowledge of the day to day experiences of individual soldiers. The theory examines the balance between aggregate experiences of stress and available resources with strong resonances to epidemiologic research on culture change, incongruity and health (Beaglehole et al. 1977; Cass el et al. 1960). Cultural incongruity was initially attributed to the intense experience of migrants, (Cassel and Tyroler 1961: 365). Like relative deprivation, research on cultural incongruity recognized Building on relative deprivation theory and epidemiologic studies of culture change , t wo central and overlapping bodies of research on population health helped to advance social theory on culture and health inequalities. Townsend Poverty in the United Kingdom (1979) based on the Black Report and the Whitehall studies conducted b y Marmot and colleagues ( Townsend and Davidson 1988 ; Marmot et al. 1978 a ; 1978b) represent two of the foundational works in what is now recognized as social epidemiology . Townsend and colleagues improved upon earlier versions of relative deprivation by giving it a more socially based definition of
46 of shared meaning and behavior that vary and overlap according to community, ethnicity, organization and region (1979: 249). Of note, relative deprivation was types of consumption and customs which are expressive symbolic meaning of material things mattered, not just their utility or use value ( my emphasis; Townsend and Davidson 1988 :249 ). For its part, Whitehall added to relative deprivation theory by demonstrating a social gradient in the exceptional circumstance of material affluence and universal healthcare among British civil servants (Marmot et al. 1978 a ). Using a data set unique at its time, researchers were able to show over time that even when all basic and modest needs were being a hierarchy in this case their rank as a civil servant explained significant additional variance in health outcomes. The conclu sion was that relative status and the stress it could cause those on the bottom was itself a stressor that could cause poor health. What was missing was a clear outline of the process. Theory on the stress process was advanced in the historical wake of Bri tish research on health inequality (Pearlin et al. 1981). Pearlin emphasized finding novel health ( Pearlin et al. 1981 :351). This emphasis eventually led to the development of a stress process paradigm that has better measured and integrated many of the same key components identified in The American Soldier such as social resources and mental he alth (see below for a brief history of stress research) . The components of a typical model now include : types of stressors, personal mediators/moderators, appraisal, responses (i.e. behavioral, affective and physiological), and physical and mental health
47 outcomes ( see Figure 1 1 as an example ; also Ice and James 2007). Anthropologists working on psycho social stress and culture change modify the stress process model by adding consideration of collective understandings to each of its components (Dressler 201 0; Spradley and Phillips 1972). A Brief History of Research on Stress and its Biological Effects . Our current understanding of stress had at least two important originators. Hans Selye is the most often cited as he did the most to promote the study of st ress. However, Walter Cannon initially coined the modern use of the word stress and first applied it in his work on its physiological effects fully 20 years prior to Selye (Cannon 1914; Selye 1936) insight that psychological variables, including anticipation, could act as stressors. Furthermore, he showed that social interactions could initiate a stress response but could also buffer against negative impacts from stress (Selye 1979) . With the help of work, the field of stress research quickly grew . It eventually became so broad that over 30 years ago, Pearlin set out to organize the major theoretical hypotheses of the field into a model of the stress process (Pearlin et al. 1981) . It is beyond the scope of this chapter to review all of theoretical contributions Pearlin sought to unite but a brief review should suffice. Wheaton summarizes four of the most important as ( 1) the Trait Hypothesis, which acknowledged that not all sour ces of stress are equa lly stressful; ( 2) Differential V ulnerability that was focused on variation in stress outcomes according to cla ss differences; ( 3) the Context H ypothesis, which recognized that variation in life experience led to different perceptions of stressors; and, 4) the Stress Domain
48 Hypothesis that tried to eliminate false distinctions between stressors (Wheaton 1996) . Building on these and other theories, Pearlin articulated the first complex model of the stress process . The stress process was first proposed shortly after Townsend issued the Black Report on inequality in Britain (Pearlin et al. 1981). It was meant to resolv e poor definitions of stress that punctuated the literature often failing to separate distinct concepts. The stressor concept was confused with a generalized stress response and with stress as a mediating variable alike (Wheaton 1996) . This created measureme nt problem s that increased the difficulty of resolving the place of stress in the causal cha in leading to health outcomes. health (Pearlin et al. 1981) . Furthermore, the stress process was proposed as a vehicle for addressing an overemphasis on studying on ly unusual cases regarding stress. It was meant to encourage study of everyday life and ordinary pursuits to gain a better understanding of social stress. Since its original form was published, work on the stress process has become paradigmatic for integr ating disparate sources of stress into testable research designs (Pearlin 2010) . Chronic stressors are also now recognized as playing a distin ct role in the stress process. Their origins can vary but all have in common that they must be dealt with on a regular ongoing basis in lives or in their minds . Whether a stressor is lingering psychic pain from a past event, or anguish from ongoing physical or emotional struggles, any ongoing stressor, even seemingly innocuous ones, have the potential to
49 cause chronic stress when they are meaningful to a person . These stressors are considered chronic, not because they happen 24 hours a day but because they are so regular that their impact is always being felt (Wheaton 1996; Glei et al. 2007) . They can be conflicts w ith people and institutions, social and neomaterial threats, and other enduring problems (Pearlin 1989) . In a twist to this usual patterning, even expected events that perpetually do not occur can become chronic and potentially cumulative stressors. Daily hassles, by contrast, are relatively minor stresses but they are often conflated with chronic stressors and overlap with criteria for psychological health outcomes such as distress. An important offshoot of daily hassles is perceived stress. Whether due to perceptions of what others think about you or your changing opinion of yourself, perceived stress is often an important contributor to chronic st ress (Cohen 1988; Singh Manoux et al. 2003) . . The available body of research on the biological effects of stress is massive. Competing paradigms exist, each with its own approach to unifying our understanding of stress. One of the active areas of rese arch in stress is allostatic load. It body (Sapolsky 2004 :9 ) . As one of variou s models of stress, allostasis is not universally agree d upon (Dallman et al. 2003 ; Sterling 2004 ) . It is, however , an important reconsideration (or even replacement) of the concept of homeostasis , which was the physiological theory the first stress researchers built upo n to flesh out their ideas . The key difference is that allostasis considers the body brain link as integral to stress responses and dynamic physiological regulation . In contrast, homeostasis separates the brain and body as two separate systems where
50 stressors work through the brain to cause dysregulation and the body then tries to return things to a set equilibrium. The concept of allostatic load builds from this idea of dynamic physiological regulation to better integrate the psychological and biological. It has led to the development of cumulative measures of allostatic load meant to predict stress bur den and disease risk ( McEwen 2009 ) . In this regard it is a similar concept to cultural consonance save for any systematic accounting for variation in the setting specific importance of psychosocial stressors. The Physiology of Stress and Its Measurement . When a stressor is perceived or detected, information from the senses are interpreted by the thalamus and processed by the amygdala which activates a physiological response (McEwen 2009) . Both the sympathetic adrenal medullary (SAM) system and the hypothalamic pituitary adrenal (HPA) system are then activated by the brain (Schneiderman et al. 2005). These systems regulate the release of hormones that make ener gy supplies available for immediate needs and shift blood flow to the brain and skeletal muscles. The result in the body is a cessation of any excess processes related to digestion, growth, tissue repair or sexual reproduction. If these processes are not r eactivated in a timely manner because the threat persists, physical development can be disturbed and neurobiological problems can arise. SAM System . (Kaplan 1978; James et al. 1989) . This includes catecholamine release, which im mediately alters ph ysiological functions for fight, flight or freeze responses . The cardiovascular system then increases blood pressure, heart rate and cardiac output resulting in more oxygen and blood for the brain and muscles. Chronic stress response
51 in the SAM system creates mechanical strain in blood vessels, increases chances of atherosclerotic plaque build up, and constricts coronary arteries, which can lead to ischemia. HPA System . The HPA provides a less immediate response to stress that ultimately leads to the release of glucocorticoid hormones (McEwen 2009) . Glucocorticoids dampen the SAM response, stimulate the immune system, and influence metabolism of carbohydrates, proteins and fats. Cortisol is an important glucocorticoid that regulates the distribution of energy resources. Chronic stress response in the HPA system, among other things, results in chronically increased production of cortisol, which has been associated with long term decreased immune function, disrupte d growth and development and phy sical damage to the brain resulting in cognitive problems. Immune System . The immune system is implicated in the stress process as a barrier to pathogens as stressors but its functioning can also be attenuated by chronic stress ( McD ade 2007) . As a defensive system it provides both innate immunity and adaptive immunity. Innate immunity functions in a generalized way in response to pathogens and represents a first line of defense. Adaptive immunity allows the immune system to pr oduce tailored responses to past threats. This includes cell mediated responses and humoral mediated responses, which address intra and intercellular pathogens, respectively. Stress Biomarkers . Biomarkers are used to measure physiological stress response levels in the cardiovascular, neuroendocrine and immune systems (Ice and James 2007) . The choice of appropriate biomarkers depends greatly on the questions
52 and outcome being investigated as well as the resources available and the constraints on sample collection at the field site. Aspects of c ardiovascular health can be assessed with measurement of blood pressure. Short term n euroendocrine alteration is most commonly assessed through cortisol measurement . Urinary, salivary and blood samples are the most frequently used collection techniques for cortisol assessment. However, because each of these biomarkers can only capture a snapshot of an ever changing system, they all suffer from measurement error when research is meant to assess chronic stress activation (Pollard and Ice 2007) . Differing cortisol baselines between distinct populations can also make comparisons difficult. Diurnal patterning of the hormone and a regular morning spike followed by decline throughout the day further complicates capturing comparable measures (Gow et al. 2010). Another threat is the pote ntial for dramatic inaccuracies in measurement of cortisol due to spikes linked to acute stress events occurring near to when the short term measurement is taken. Urinary measures are the best of the short term measurements for assessing systemic cortiso l levels as they attenuate measurement error due to fleeting spikes by assess ing levels of hormone over an entire 24 hour period. However, these samples are hard to collect and promptly analyze away from a clinic. Ultimately, they can only provide a retro spective cortisol measurement for one day. Salivary samples are the easiest to collect and cheapest to analyze but can be biased by the time of day they are collected since cortisol spikes in the morning and decreases the rest of t he day (Pollard and Ice 2 007). This cortisol waking response has proven an important indicator of health in and of itself, though it likely measures distinct processes from those indicated by mean cortisol levels over time (Steptoe et al. 2004).
53 The common practice of multiple sel f collection s to obtain diurnal patterning can introduce measurement error from the sheer number of people collecting samples (every participant) , each of whom may be using a slightly different technique or collecting at slightly different times . Even more critically, there is typically no validity check on the time of sample collection due to logistical constraints . Yet consistency in this regard is critical for comparison of individual measures. For measurement of chronic stress, salivary cortisol also su ffers from the potential of outlier measures occurring when sample collection happens immediately after a stressor has been experienced thereby skewing calculations of average results in the case of an acute stressful event . Blood samples are moderately d ifficult to collect and may face more stigma in field work than other biomarkers (McDade 2007 ) . Their storage, transport and analysis, however, is relatively easy and straightforward when blood s pots on filter paper are used. Like all short term measures, a nalysis of cortisol in blood suffers from measurement error when unidentified acute stressors cause temporary spikes in Finally, two emerging alternatives to the se common measures include hair cortisol analysis and nail cortisol an alysis (Gow et al. 2010; Warnock et al. 2010) . Both of these methods overcome the threat of over estimation due to acute s tress cortisol spikes as well as the diurnal measurement biases of salivary and blood assessments while matching or exceeding ease of collection in the field. Hair and nail sample collection is also easier than urinary sample collection for field studies. These measurements can provide a retrospective average record of systemic cortisol from a
54 few of weeks (nails) to 12 months (hair) depending on the method and size of the sample. The largest drawback at present to these methods has to do with potential m easurement error from aesthetic hair and nail treatment comm on in industrialized settings. This threat may al so be systematically gendered. The effects of such treatments are not clear but seem to generally cause leeching of cortisol from samples (Gow et al. 2010) . Populations that do not have high rates of such treatments do not suffer these threats to measurement validity. Finally, a drawback to nail and hair cortisol is their relatively thin track record in the li terature due to their novelty as cortisol measures. Culture Change , Market Integration and Psychosocial Stress Non industrial societies exposed in situ to market economies undergo a transformation. This change, h owever, is more protracted than among migrants who experience market exposure (Baker et al. 1986; Chin Hong and McGarvey 1996) . The speed of in situ exposure also depends on whether people have the freedom to choose to maintain their traditional livelihood patterns. Still, many eventual outcomes are quite consistent for exposed groups. At a societal level, a newly contrived social hierarchy forms on top of what had previously been comprised solely of long established local salient factors (McDade and Nyberg 2010 ; Roseberry 1989 ). Markers of status are put in flux and the old hierarchy comes to subsume new priorities common to or required by market commoditization. The fact that in situ market exposure leads to a shift in status markers at all hints at imbal ance between the old and the new. Push and pull factors that induce individual integration can often be seen to already outweigh some culturally salient life priorities. The result of market integration is typically an increase in the severity of social gr adients
55 through the emergence of income inequality (Marmot 2002 ; Piketty 2014 ). The potential long term societal consequences of market integration, however, have long been debated. Most economists either believe that growing inequality is inevitable and must be controlled or that real inequality is not very substantial and what does exist naturally subside s as economies mature (Godoy et al. 2004; List and Gallet 1999) . Coming to understand and intervene to reduce income inequality has recently taken on a new public urgency in light of novel analysis and policy reco mmendations . makes a convincing case that inequality tied to growth in capitalist market economies is not naturally correcting . Specifically, the economist Simon Kuznets and others predicted in the 1950s that there would be natural reduction in economic inequality in all developed economies. That is, the increasing inequality that seemed to accompany developing economies was supposed to reverse naturally. This led to the widely held belief th that the opposite has come to pass. As time passes and development increases the rate of return on capital (wealth, rents, property, etc.) outpaces in creases in income and inequality increases . Therefore, in the historical data inequality hits its nadir at the midpoint of economic development before subsequently ramping up again. This evidence makes the work to understand links between inequality and h ealth even more critical and urgent now , since arguments for systemic self correction have lost much of their legitimacy. A logical place to start is with the structural drivers that shape the very emergence and meaning of inequality (CSDH 2008). These as pects are important
56 because in industrial societies individual and community level referents of relative status not absolute deprivation account for the majority of variance in health outcomes (Adjaye Gbewonyo and Kawachi 2010; Lim et al. 2012; Wilkinson and Pic kett 2007) . To improve health, we need to pinpoint the mechanisms underlying the increased severity of social gradients in industrial market economies versus non industrial societies. Studying this difference can provide novel comparative insight into w hat instills meaning into the experience of inequality. Biological anthropologists have linked the historical development of social stratification to agricultural intensification, sedentarism and population growth (Armelagos et al. 2005). Anthropological r esearch on culture change has examined five key pathways that lead to poor health: ( 1) behaviors, ( 2) distress, ( 3) health care, ( 4) demographics, and ( 5) t he natural environment (McDade and Nyberg 2010; Steffen et al. 2006). Depending on the society, howe ver, the relative contribution of these pathways differs . For example, a sudden shock can occur and resolve such as a flood or pestilence that ruins crops or kills a significant number of people. Alternatively, a slow accumulation or social lag of changes in behavior and demographics can push and pull at communities over time, like those who experience integration to markets in situ (Cassel et al. 1960; Hull 1979; McDade 2009; Scotch 1963; Spradley and Phillips 1972). However, questions remain about exactl y when kin based groups practicing subsistence agricultural first experience a severe social gradient in health as a result of market exposure above and beyond those due to traditional patterns of social stratification .
57 Searching for more clarity, biocult ural anthropologists critique and refine the social gradient concept in at least three important ways. First, they point out that most research conclusions are drawn from studies of singular and homogenous populations, such as British civil servants in th e Whitehall studies who shared government jobs and healthcare, kinship structures and an economic system (Marmot et al. 1978 b ; McDade 2009). Without such homogeneity we cannot assume equal access to material resources and healthcare or coping and resistanc e resources. Instead, these factors must be appropriately measured and understood to get a clear picture of social stratification and health (Dressler 1995; Goodman and Leatherman 1998). The second important critique is that social status is only as import ant to health as the sharing of knowledge and behavior driving it; a contested cultural model of social status will not have the same impact on health as a more universally shared one because its symbolic significance is reduced (Baer et al. 2003; Chavez e t al. 2001; Wilkinson and Pickett 2009). However, few studies of health inequalities examine cultural models explicitly. A third important critique is that traditional kin based societies have distinct systems of social status and support, both material a nd symbolic, which can alter the impact of psychosocial stress and material deprivation (Dressler 2010). These critiques point out the important interplay between cultural construction and social structure that must be understood to improve h ealth outcome s. Bourdieu (1989: 14) addressed the theoretical challenge of simultaneously considering structure and agency in his articulation of a structural ist constructivism theory. He argued that there are objective structures independent of consciousness that func tion concurrently with our symbolic systems of language, myth and meaning (Bourdieu 1989: 14) . This
58 duality of structure and agency means that failing to measure both together can re sult in misleading conclusions informed by only a partial version of reali ty . Recent research on ethnographically informed cultural incongruities (i.e. in lifestyle, status and color) and cultural consonance (i.e. in lifestyle and social support) operationalize much of this theory and forcefully demonstrate the value of understandin g the individual vis Ã vis the group in the final analysis (Chin Hong and McGarvey 1996; Dressler 1991; Dressler et al.1997; Janes 1990; McDade 2001; Sorensen et al. 2009). Cultural incongruities are found when there are conflicting ideals in group s , cultu re s or societies such as a desire for high socioeconomic status and an expectation to maintain cultural knowledge and practice, both of which require time and commitment to achieve. Cultural consonance, in particular, assesses the difference between what people perceive as desirable in life versus what they perceive as their actual lot. Stepping from theory to research can help clarify this approach Below I review t hree examples that I think highlight the nuance captured by biocultural research . First, McDade found that among highly socially integrated adolescents in Samoa, those with low levels of incongruence in lifestyle ( i.e. SES compared to locally defined lifestyle) had the lowest stress mediated immune activity overall ( 2001) . In contrast, those w ith high levels of incongruence had the highest stress mediated immune activity (McDade 2001). Clearly, the pursuit of an incongruent lifestyle, even with high SES, proved stressful for these young people. Next, among the Yakut in Siberia who recently ret urned to a traditional herding lifestyle after the fall of communism Sorensen identified two distinct models of lifestyle that modulate d the effect of physiological stress responses in different ways ( Sorensen et al. 2009).
59 Specifically, respondents either preferred a market lifestyle or a traditional lifestyle . For those respondents who preferred a market lifestyle but failed to achieve its agreed upon goals, their stress responses were the highest overall for both of the lifestyle types. Mean while , those following and succeeding at this same market lifestyle had the lowest overall stress responses for both of the lifestyle types . Alternatively, incongruence had little effect on stress response for those following a subsistence lifestyle . For the Yakut, th en, it was the actual type of subsistence culture addition to incongruence that seemed to moder ate the stress of social stratification . A consensus measurement model in synthe tructural ist c onstructivism. He extends cultural consensus modeling using cognitive anthropological theory and creates an anthropological stress process model and cultural consonanc e measurement ( Dressler 2001). At its most basic c ( Dressler 2001 behavior correspo nds to local cultural models about the conduct of everyday life, the 2005). Evidence from this work clearly shows that failing to approximate cultural ideals (i.e. having lo w cultural consonance) increases psychosocial stress and leads to worse health. Anthropological research on the stress process has improved measurement of psychosocial stress cross culturally where shared meaning, knowledge and behavior especially related to perceived stress and self reported outcomes often vary (Dressl er
60 1984; McEwen 1998; Seligman and Brown 2010 ). Improved measurement is possible through synthetic use of ethnography, systematic cultural modeling, and epidemiology, which together allow for a more ethnographically valid assessment of chronic stressors through triangulation of research outcomes (Dressler 2007a; McDade 2007; Trostle 2004 ). Anthropological research has done more than just prove that culture matt ers in social status and health. I t has also shown that an integrated measurement model reveals processes that are understudied (Dressler 2005). One gap that exists in the biocultural research on the stress process is a lack of work among groups with minimal market exposure. Instead, bio cultural research has included groups with moderate to heavy exposure, a high ratio of acculturated individuals, wide access to diverse market goods and income from wage work (Dressler 2007a; Gravlee et al. 2005; McDade 2001; Sorensen et al. 2009). Biologi cal Anthropology and Adaptation Theory This research project aims to synthesize traditional participant observation and analysis informed by historical and political economic processes with empirical measure ment s of culture sharing and individual level ass essment of social, cultural and biological variation. A central goal is to clarify mechanisms underlying the development of social and health inequalities in a setting of rapid integration to markets and culture change. A starting point for this synthesis of the foundational concept of adaptation theory in biological anthropology . His work aims to better reflect social and political realities and not just de contextualized biological consequences of adjustment (Thomas 1998) . It adds a political economic lens to compliment an existing focus on environmental constraints and human biological responses.
61 dvances during the last 25 years of the 20 th century in biological anthropology that were (Goodman and Leatherman 1 998 :15). As Goodman and Leatherman point out, t he drive to learn and exploit emerging techniques such as polymerase chain reaction for genetic analyses seemed to overshadow work to assess the root causes of socioeconomic variation and historical forces of change. But in this fury the inadequate and largely refuted adaptationist program did not change and continued to drive research questions and interpretation of result s. This period of work in biological anthropology was rightly critiqued by e volution ary biologists who pointed out that we have long known the discovery of variation is not the same as proving the functional import of a particular variable (Gould and Lewontin 1979) . T o evaluate the functional import of biological processes, theory had to account for more than just social and biological interactions of humans with their environments over time. A critical missing piece to th e adaptationist paradigm was a place for ind ividual agency within structure, which requires better measurement of variation and change in the shared knowledge and behavior that makes up culture. The objective of political economic/adaptation frame work is to more (Thom as 1998:44). It acknowledges the important role of assessing meaning in inequality research and promotes a program to execute this goal. The framework outlines five areas of focus germane to such a synthesis, ( 1) historical conditions and political econom ic processes that give structure to actions, relations and health, ( 2) local
62 social and environmental conditions of opportunity and constraint, ( 3) identification and effectiveness of local psychobiological and sociocultural adjustments, ( 4) adjustment con sequences for households, social interactions and environments, and ( 5) local responses to conditions and the feedback loops related to those resp onses. A gap in this synthesis is that it leaves little theoretical room for the role of individuals and does not ex plicitly measure culture (Wilk and Cliggett 2007:113). and surreptitious mechanisms, it is also necessary to pursue a more systematic study of culture. In particular, related to this research a focus on individual approximations to cultural ideals is needed in the analysis of markets, change and health (Dressler 2010 ; Mcdade and Nyberg 2010) . The choice of doing either/or is a false one. Simil arly, systematic cultural modeling and individual assessments should be based on a foundation of long term participant observation. Participant observation allows for insights on locally grounded perspectives that are simply not possible thro ugh limited s emi structured interviews or survey research based largely on self reported variables ( Bernard 2011 ) . This classic anthropological method is the key to assuring that researchers not only know the right questions to ask, but how to ask them (Briggs 1986) . Observing and participating is so essential because it can aid in development of a nuanced interpretation and commun itie s words, actions and narratives. It acquired guidelines that tell us how to view, experience and behave in the world instead acknowledge s that culture supplies resistance resources and frames of contestation and struggle over power (McKenna 2008:207). Combining the focus of
63 the method of participant observation and the cultural consonance meas urement model addresses head problem, as sociologist s Anthony Giddens and Pierre Bourdieu have explained it ( Bourdieu 1989; Giddens 1979 ; Karp 1986) . Put simply , how to account for the group and individual simultaneously. The Meaning of In equality in a Non Industrial Society Amerindians hav e played an important role in the development of s ocial theory about inequality. Marx (186 7) argued that in industrial nations the production and exchange of commodities concealed and obscured meaningful social relations by increasing class inequalities. W hen new theory from anthropologists of lowland South America emerged to describe novel ethnographic findings on social structure and kinship during the mid 20 th century, Levi Strauss (1963) argued that these pre industrial social relations themselves acted as a smokescreen for inequality. He re analyzed kinship data on lowland Amerindians and concluded that dual organizations (i.e. binary symmetrical social systems) and social fluidity worked to conceal social asymmetries . Leading ethnographers of the regi on have since rejected this conclusion saying in part, native metaphysi Lewis 2009: 919). Maybury Lewis (2009) makes a strong case that Levi Strauss misinter preted dualism due to a dearth of information on native metaphysics. The dualities in these societies, he argued, are complimentary and quasi egalitarian social arrangements. The episode demonstrates the necessity of using ethnography to explore beyond str uctural analysis in order to answer questions about how beliefs affect market integration and health.
64 because it underlines how market exposure is much more than just exchange with outsiders but also a shift in shared meaning and in the very way life, time and material items are valued and perceived whether this value is individual ly agreed upon or not (Lu 2007: 593). A review of literature on the consequences of market integration among indigenous group s has not always been consistent regarding the definition of exposure and integration. Results have been found to vary dramatically due to differen ces of definition and the variables used to measure integration (Godoy et al. 2005). In research but lack of contextual nuance. This is both because data on context are wanting and because synthesis of this data with survey research is lacking. This has prevented the analysis of fluid factors rich in meaning such as symbolic status. Like Levi conclusions on dualism, missing information can lead to misinterpretat ion of finding s and knowing more about context will help to prevent this threat. Market Integration and Indigenous Health There are an estimated 48 million indigenous peoples in Latin America (10 % of the population), 16 million of whom live in South America (Stephens et al. 2005; Montenegro and Stephens 2006) About a third of all indigenous peoples in South America (5.4 impoverished country (UN 2009; WHO 2009). The health and well being of the vast majority of indigenous peoples throughout the Americas have long suffered in comparison to that of Europeans wh o colonized their lands and whose descendants have maintained power and influence there for centuries (Stephens et al. 2006) . In
65 South America this ineq uity continues to exist most sever e ly in Bolivia in part because of the extreme difference between a small group of rich elite and the vast majority of the population that is poor and indigenous. T he percentage reports as indigenous is higher than anywhere else in Latin America or the Caribbean (Montenegro and Stephens 2006) . Different data sourc es report a range from 55% to 71% of the total population as indigenous (Capdevila 2006; Montenegro and Stephens 2006 ; CIA 2009). The combined total of indigenous and European/ind igenous mixed populations is closer to 85% (CIA 2009). A large body of cross sectional research demonstrates the overwhelmingly worse average health of indigenous peoples (without regard to their level of market integration) compared to westernized populations (Montenegro and Stephens 2006; Gracey and King 2009) . Par t of this burden comes from the synergistic and syndemic effects of multiple endemic chronic stressors and diseases commonly found in marginalized communities (e.g. chronic experiences of stress linked to weight gain and greater centripetal fat distributio n and high rates of coronary heart disease; Dallman et al. 2003; Singer an d Clair 2003) . Culture change and market exposure are therefore not the exclusive sources of indigenous health inequalities. A lack of group political and economic power in the context of the nation state is also to blame (Thomas 1998). Research can be improved by considering how indigenous separation from, and exposure to, markets is modulated at different levels regarding push and pull factors to sell or vacate lands, reorganize communities and political structures, and adopt new languages or metaphysi cs . Improvement can also come from better measurement of
66 local perceptions of autonomy and ideal lifestyles, which affect experiences of psychosocial stress (Dressler 2004) The inequalities suffered by indigenous and poor populations in Bolivia since colonization have led to many successive uprisings, government takeovers and subsequent violent and less violent coups d'Ã©tat the last of which occurred in 2005 (Postero and Zamosc 2004) . Throughout this history the health of the over 30 different indigenous groups there has largely remained poor or even deteriorated (Postero and Zamosc 2004) . The recent re emergence of Latin American Social Medicine in Ven ezuela with support from Cuba has begun to strongly influence Bolivia and the current Morales administration regarding its approach to health reform. This has led to an increasing push to focus efforts towards the social determinants of health at indigeno us, local, municipal, regional and national levels. Bolivian Policy and Indigenous Health During the last decade Bolivia has undergone a dramatic political transition. In 2005 the country elected its first indigenous president, Evo Morales, an Aymara Ameri ndian often considered a highlander who was raised in a family of colonist coca farmers in lowland Bolivia . Before Morales took office, three presidents in three years were forced to step down amid social unrest (Garcia 2009) . President Morales was accompanied in his win by many of his fellow MAS party members who achieved a majo rity in the lower house of the bicameral legislature (BBC 2009). With this sea change in the political environment some of the push for reform by the indigenous majority has shifted from a force located outside of the government to an internal one. Still, the efforts of President Morales and MAS during his first four year term have been stifled by fierce opposition from a coalition of conservative political parties including a
67 majority in the upper house of congress. Despite this opposition, in January 200 9 voters approved a new constitution by special referendum that expands rights for the indigenous majority including major policy initiatives to improve health . Included in the referendum was approval for the addition of seven new seats in the legislature specifically reserved for indigenous representatives meant to permanently increase the presence and power of indigenous peoples in the Bolivi an federal government (BBC 2009). President Morales and the MAS party have made redistribution of wealth the fou ndation and engine of their movement. Funds have come from natural resources , in particular from natural gas , that the government has partially nationalized on the grounds that its past privatization was illegal . MAS the party meant to represent the inter ests of the historically powerless Bolivian poor, the majority of whom are indigenous is struggling to balance alleviating some of the suffering of the majority population while managing not to foment a civil war in a country that has recently dealt with e normous turmoil . In September 2008 Mr. Morales and his administration were and frequently violent protests in lowland departments that are home descended elite that sees its interests (Rome ro 2008) . These struggles have come as Mr. Morales has proven himself an effective socialist minded president in the mold of Hugo Chavez and Fidel Castro. He has already nationalized much of the energy sector and telecommunications and pledged further radical measures to help redistribute wealth including raising taxes on foreign mining firms. The government is also working to re distribute 1/5 of Bolivia's la nd to
68 peasant farmers (BBC 2009). With the last election on December 6, 2009 Morales and MAS n ot only gained reelection to five year terms under a new constitution but they consolidated their win by gaining the majority of votes in six of nine national departments. This was an unprecedented show of support by voters in an election deemed free and fair by independent observers (Painter 2009) . E ven by neoliberal standards (i.e. a focus on growth above all else) current Bolivia n policy has led to an economy that is outpacing the rest of Latin America an d much of the developed world. The International Monetary Fund (IMF) says Bolivia posted the highest growth in all of Latin America for g ross domestic product during 2009 at 2.8 % . And the economy grew 3.2 % in the first six months of 2009 alone, even with lower export income for natural gas, a main source of revenue for both the private and public sectors (Garcia 2009) . Two credit agencies recently upgraded Bolivia's credit ratings on the basis of the country's go od macroeconomic performance inc luding its above trend growth. Growth has been attributed to good government leadership in the process of debt forgiveness from the World Bank and the IMF. And in a twist, the paucity of foreign banking interests in the An dean nation and absence of bad debts prevalent in developed markets actually helped Bolivia avoid direct consequences from the global Great Recession beginning in 2008 (Garcia 2009). In all, according to a recent analysis by the Washington based Center for Economic and Policy Research (CEPR), government revenue increased by almost 20 % of gross domestic product since 2004 and President Morales has plowed this into social security and domestic development programs (Painter 2009; Weisbrot and Rosnick 2009) .
69 Despite the progress in overall economic performance and policy there remains a very complex political reality in the country with extreme subnational differences between regio ns and even indigenous group s. These differences have been partly attributed to the history of how the government has engaged with the Andes versus the Amazon ian regions during the last two or three centuries (Yashar 2005) . For example, corporatist state policies of the past long protected Indigenous l ocal community autonomy , to a point, in the countryside of the Andes but this began to reverse as democracy took root in Bolivia during the 1980s and 1990s. During this same period, colonists and businesses alike began to escalate intrusions into the lowl and Amazon region challenging indigenous territorial autonomy there and demanding rights to colonize what they perceived to be under populated and underutilized territory . In this way , the goals of indigenous peoples in the Andes became about protecting , r eg aining and expanding local community autonomy while in the Amazon regions indigenous groups became more focused on territorial autonomy to keep out colonists (Yashar 2005) . While these struggles were playing out, development programs were being disma ntled in the 1980s and 1990s in order to abide structural adjustment policies imposed by the IMF and World Bank (Laurie et al. 2005) . These loans helped to shore up a shaky national economy but did little to improve the lot of poor and indigenous groups. During this same period several organizations of workers and minority groups began fighting to maintain their rights in Bolivian civil society and for the general maintenance of state programs and governm ent jobs threatened by the new measures. T he Confederation of Indigenous P eople of Bolivia ( ConfederaciÃ³n de Pueblos
70 IndÃgenas de Bolivia or CIDOB), the national organization for the indigenous movement in Bolivia, was founded in October 1982, in Santa Cru z de la Sierra, with the participation of representatives of four indigenous peoples from the Bolivian East: Guarani izoceÃ±os, Chiquitanos, Ayoreos and Guarayos (Stephens et al. 2005) . CIDOB has grown since then and now represents 34 unique Indigenous peoples in lowland Bolivia. The Union Confederation of Bolivian Farm Workers ( ConfederaciÃ³n Sindical Ãšnica de Trabajadores Campesinos de Bolivia or CSUTCB) was founded even earlier during 1979 and was initially mostly made up of highland indigenous groups. The CSUTCB is known especially for having led large protests for indigenous rights in April and September 2000 during the Water Wars . They also led large protests that forced the resigna tion of President Carlos Mesa in 2005 leading to the eventual election of Evo Morales later that year (Postero 2005) . The CSUTCB protests were labeled by some as them from other indigenous movements in the country th at claim different prioriti es. For example, while other indigenous peoples rights, is more focused on gaining entrÃ©e to the political system and the Bolivian state (Solimano 2005) . Postero notes that the protests led by CSUTCB were a response not only to e conomic concerns, but also to, profound questions about the meaning of citizenship and the role of civi l society in neoliberal Bolivia ndigenous groups have allied with other sectors hit equally hard by economic crises, such as the urban poor, students, and peasa nts . This alliance across class and ethnicity has formed a new Bolivian public, which is both poor and indigenous, and
71 which is acting to expand the meaning of citizenship by demanding inclu sion in public decision making ( Postero 2005 :73) . The 1997 2000 St rategic Health Plan emerged during this period and was designed to develop the Bolivian health system to serve all citizens equally . Its main goals were to ensure universal access through individual, family, and community primary health care , create an eff ective epidemiological surveillance system for major endemic threats, provide short term basic and social insurance and promote healt hy municipalities (PAHO 2009). In 2003 Dr. Javier Torres Goitia Torres, adviser to the new minister of health in Bolivia, s tated in a presentation about the Strategic Health Plan at an ILO precarious political culture of a population, which results from the conditions of poverty and exclusion in which mos t of the population lives. Today, no political party in [Bolivia] PAHO 2005:77 78). had at last overcome the hurdle of obt aining an electoral mandate with over 63 % of the popular vote and majorities in both houses of the legislature ( BBC 2009). What many had so recently thought was impossib le had quickly become reality. T his reality , however, left the powerful global north i ncreasingly at odds with a reformist Bolivia and its allies in South America and the Caribbean. Both before and after the elections , political controversy led to a chilling of r elations with the United States, its agencies and its representatives in the re gion. For example, i n 2008 Bolivia kicked out the U.S ambassador f or allegedly plotting against the administration of Evo Morales, which led to the U.S. threatening to withdraw financial aid funds (BBC 2009). After the election,
72 he actions of the United States Ambassador to Bolivia led to suspension of privileged government relations between the two countries including limits on embassy and consular services. These events are significant because of the nce over the largest developmen t banks, the IMF and World Bank, which in the past seems to have had a muffling effect on objection s to U.S. actions there. Before Evo Morales came to power, i ndigenous rights group s did most of the legwork to unify interests and consolidate power. I n the 1990s they also played a critical role in enact ing some popular reforms. Two of these were the Popular Participation Law (PPL) and the Agrarian Reform Law. The PPL allowed for local social organizations, in cluding indigenous groups, to be recognized by the state and to influence municipal investment decisions through a planning process that occurs in coordination with the municipality. If financial management in the municipality comes into question, communi ty committees can request municipal account freezes and fraud investigations, the results of which are reported to the public by the federal government (Pacheco 2005) . In this way , PPL for the first time allowed greater exercise of political pow er at the local level. Unfortunately, soon after its initiation PPL came to be seen as only capable of providing temporary solutions, not lasting change ( Pacheco 2005 ). P aired with the popular PPL and Agrarian Reform Law was what would quickly become a very unpopular set of econ omic reform s called "capitalization. " This transfer of public wealth to private entities occurred through the sale of controlling interests in five of the largest state firms in exchange for IMF and World Bank loans (Postero 2007) .
73 It was these very same laws that President Morales effectively reversed when he took power and re nationalized the natural gas industry a nd other former state firms. Just before this occurred and during massive political turmoil, Bolivia n politicians finally took action to enact new constitutional laws in 2004 to address the past invisibility of minority and socially excluded groups recogn izing, ( 1) multicultural nations, ( 2) indigenous peoples as distinct groups with specific constitutional rights, and ( 3) indigenous customary law 2004) . As a result of these laws the Indigenous Affairs Division of the Ministry of the Interior was created to address structural poverty and disad vantage. Additionally , preferential policies such as scho larships, quotas for hiring, quotas for political parties, anti discrimination legislation and enforcement through civil protection were created to address discrimination of formerly socially exclude d groups in employment, accommodations, education, trade union membership and provision of goods and services 2004) . Overarching policy reforms since that time also include l iteracy programs that have been implemented with the aid of Venezuela and Cuba to increase human capital and decrease gend ered disparities in ed ucation. The first stage of a three year national literacy program came to a close in 2009 having reached 819,000 people some 99.5 % of the estimated illiterate population as of D ecember 2008. This makes Bo livia only the third country in Latin America to reach full literacy. T he program now continues into its second phase aimed at increasing literacy in native languages (UNICEF 2009). S tate projects to improve infrastructure are also slowly improving roads and installing better sewage a nd water systems ( UNICEF 2009 ). But some of these same projects threaten indigenous livelihoods and health especially in the lowlands because they encroach on
74 lands and facilitate access by outsiders looking to take advantage of raw materials or colonize n ew territory. and largely due to the 1997 2000 Strategic Health Plan, Bolivia was ranked second in Latin America for its quality of legislative support for the health and well being of indigenous average pro from the IMF and World Bank (Laterveer et al. 2003) . Aiding in this status has been strong support from successive administrations to maintain continuity within the health sector (ILO PAHO 2005). Currently, the government is spending USD $320 million a year in gran ts to encourage parents to keep their children in school, in pensions for the elderly and in cash handouts to persuade pregnant women and mothers to go through health checks (Garcia 2009) . D ue to the re nationalization of former state firms, high natural gas prices, debt relief and reduction in external loans, d ebt servicing decreased dramatically from 1990 when it equaled 31% of exports of goods and services to 2006 when it was just 8%, which is partly responsible for freeing up funds for more social programs (UNICEF 2009). An other analysis of health policy rele ased in December 2009 by researchers at CEPR in Washington, D.C. also found that Bolivia has significantly increased spending on social programs aimed at health and education for the poor (Wei sbrot and Rosnick 2009) . The debt relief program that has overseen debt forgiveness of the majority of
75 coverage, coverage for treatment of acute respiratory infection in children under 5 years old, acut e diarrheal disease in children under 5 years old and DPT3 immunization coverage (three do s es against Diptheria, Pertussis and Tetanus) in infants under 1 year of age as proxies to judge overall health system improvement ( PAHO 2009 ). Unfortunately, among i ndigenous groups with high infant mortality rates and long travel di stances to health care clinics, many still fail to receive the se inoculations. Re nationalization of state firms combined with debt relief has provided direct funds for healthcare. Specif ically, Basic Health Insurance (BHI) is a policy instrument funded with hydrocarbon revenue that was designed to guarantee all inhabitants permanent access to a series of promotional, preventive, and curative health benefits at a sustainable cost (PAHO 200 9). This system provides care and support for children under 5 years of age, immunization programs and nutrition, and diagnosis and The three major cash transfers laid out as a part of BHI include Bono Juanci to Pinto, Renta Dignidad (the pension program), and Bono Juana Azurduy. Data on these social security programs see m to show that they are making a difference in an efficient way. For example, a 2004 study of Bonosol (the progenitor of Renta Dignidad) foun d that the realized value benefit from the pension for impoverished households in Bolivia was actually multiplied one and a half times its original value due to recipient use of the funds to grow more food and buy livestock (Martinez 2004 ) . This result bodes well for the newly expa nded system of cash transfers to improve the
76 Bono Juancito Pinto gives BOB$ 200 (approximately US D $29) ye arly to children as an incentive to continue their education through the sixth grade (Martinez 2005) . Renta Dignidad began in 2008 but was preceded by Bonosol, which was the original n eoliberal reform attached to national debt relief programs. Renta Dignidad, unlike Bonosol, has been anchored to a n explicit social rights agenda (MÃ¼ller 2009) . It gives grants to all low income residents over age 60 to prevent ex treme poverty among the elderly. This includes BOB$ 1 , 800 (approximately US D $258) to those who receive social s ecurity payments, and BOB$ 2 , 400 (approximately USD $344) to those who do not (Garcia and Grey 2009). Bono Juana Azurduy (also known as the Bono Madre NiÃ±o NiÃ±a) began in May 2009. It gives funds to uninsured new mothers to seek medical care during and after their pregnancies. New mother s receive BOB$ 50 each for four pre natal medical visits, BOB$ 120 for the childbirth, and BOB$ second birthday (Weisbrot and Rosnick 2009) . Unfortunately, the potential f or these programs to improve the lives of indigenous peoples has been slowed by poor access and uniform requirements of registration and birth certificates for receipt of benefits. Large numbers of indigenous people have none of these documents so many re main ineligible for benefits ( HelpAge 2009) . There is still plenty of room for improve ment in the national health system. For example, Rousseau (2005) points out that welfare benefits in Bolivia for a long time had So while some categories of women those that are either pregnant or new mothers were entit led to universal heal th care services free of charge, other women and men were not. New programs have started to change this
77 with i nfants under five years old now covered. Still, as late as 2007, 79 % of the population lacked any type of insurance, and social insurance covered only 4 % of the population in rural areas, where indigenous groups are concentrated (Mesa Lago 2007) . Bolivia health policy goals have also been expli citly spelled out in the National Development and Strategic Health plans with a view of health as a human right (WHO 2007). These goals include the reduction of inequities and exclusion, specifically in gender and for indigenous peoples as well as reductio n of malnutrition to zero levels and reduction of family violence. This approach is supported by evidence of its local effectiveness. In a 2002 developmen t intervention project a imed at improving health i n impoverished areas of Bolivia, researchers found that outcomes were enhanced when leadership within formally established grassroots community organizations was strengthened through training and assistance (RÃos et al. 2007) . Also, interventions were found to be more successful when a) promoters spoke and wrote native languages, b) women participants were more motivated and empowered, c) projects were designed to be responsive to priorities identified by the communities and, d) health services wer e made culturally suitable. The overall policy focus on social justice begins with the new constitution. The WHO compiled a summary of key points from the document regarding social justice for indigenous peoples that demonstrates this focus . Article 1 of the Constitution proclaims that Bolivia was founded on political, economic, legal, cultural and linguistic pluralism Bolivian men and women, Indigenous nations an d peoples, peasants, and inter cultural and Afro Bolivian communities, which jointly make up the Bolivian people
78 2009). Article 98 (I) says Plurina 2009) Moreover, it states th at culturalism is the instrument for the cohesion and balanced harmonic coexistence among all peoples and nations. Interculturalism will recognize differen ces and equality in conditions, (WHO 2009). The Constitution estab lishes that it is a fundamental duty of the State to preserve, develop, protect and disseminate the existing cultures. Finally, A rticle 100 says, the heritage, worldview, myths, oral history, dances, cultural practices and traditional knowledge and technol ogy of Indigenous nations and peoples are considered part of the identity of the State, which is obliged to protect them (WHO 2009). The Bolivian n ational p olicy goals that follow from these constitutional laws aim to address the most important social dete rminants of health . To make these explicit, we can refer to a seminal study by WHO in 2003 that reported the 10 most important known social determinants of health as , ( 1) the social gradient /unequal status , ( 2) stress, ( 3) early life, ( 4) social exclusion (e.g. reduced power/agency due to poverty and/or discrimination), ( 5) work, ( 6) unemployment, ( 7) social support, ( 8) addiction, ( 9) food, and ( 10) transport (CSDH 2008) . Health and Well Two decades of increasi After several decades of unchanged life expectancy rates, longevity increased from 1990 to 2000 by ten years going from 43 years at birth to 53 (Gurven et al. 2007). Longevity is still constrained by an infant mortality rate that has remained constant for the last 50 years and is now twice that of the rest of Bolivia ( Gurven et al. 2007 ). However, infant mortality rates vary from 178 per 1000 people in villages most distant
79 from a market town to 100 per 1000 in those closest to the market ( Gurven et al. 2007 ). Meanwhile ave rage individual wealth (a proxy for market integration) is associated with worse self reported health (Undurraga et al. 2010). Objective physiological measure ment s among a reflect a pattern of health change, with people living nearer to a market town having higher levels of short term cortisol levels an indicator of temporary psychosocial stress (Nyberg 2009). Average population short term cortisol levels, though, are the second lowest ever reported ( Nyberg 2009 ). Health outcomes typically linked to chronic stress including peripheral artery disease, lipid levels and hypertension have similarly been found to be some of the lowest ever measured (Gurv en et al. 2009; Vasunilashorn et al. 2010). As opposed to other physiological measure ment s, inflammation and immunity biomarkers of chronic stress have rendered more complicated results (Gurven et al. 2008; McDade et al. 2007). Levels of inflammation have been found to be very high measured with C reactive protein (CRP) and interlukin 6 (IL 6) and immune systems highly taxed measured with Epstein Barr virus (EBV) and immunogl obulin (Ig) E (McDade et al. 2007) . In industrial settings, this pattern typically indicates chronic stress. , however, inflammation and immune function are strongly associated with high parasitic loads and not likely related to psychosocial stress (Gurven et al. 2008). T he study of market integration frequently suffe rs from a division in research priorities. Medial sociologists, ecologists, economists and epidemiologists most commonly assume the independence and near complete agency of individuals.
80 Anthropologists by contrast , are more likely to consider groups or c ultures and their overall similarities while glossing over individual variation due to a central goal of cultural comparison (Karp 1986) . I n a reversal of this norm, however, the vast majority and econome tr ic research theory and design. These approaches set the individual as the unit of analysis and househo lds and communities are understood as indicator variables to be controlled out . Furthermore, m ost of the research has not been systematically informed by ethnographic assessment of emic perspectives on change in social status, social relations and material lifestyle (Undurraga et al. 2010). This makes interpretation of quantitative analyses more difficult and less useful (McK enna 2008). A biocultural approach would be useful for help ing to uncover the important stressors acting both in the open and hidden from individual perception and conscious observation . The is because the usual approaches to ethnogr aphy and biological anthropology alone are limited for this purpose ( Dressler 2010) . For example, ethnography cannot assess embodied stressors at a physiological level and a survey focused on biomarker measurements may fail to adequately account for cultural context. Ethnography, Meaning and the History of Research among relied heavily on second hand accounts from neighboring indigenous groups (NordenskiÃ¶ld 1915 ; Metraux 1942). More in depth work on social organization and kinship came much later (e.g. Daillant 2003; Ellis 1996) including one extensive treatment on traditional metaph ysical cosmology and myth (Huanca 2008 ). Earlier em of cross cousin marriage
81 (75% maintain this practice), make regular and often long term (months long) visits between distant villages to bolster social ties, and move families and villages as frequently as every few years ( Chicchon 1992; Daillant 2003; Elli s 1996 maintain many of th a first language (70 % monolingual) and residence in tight knit communities (Undurraga et al. 2010). Extensive longitudinal (Leonar d and Godoy 2008) and addresses many of the shortfalls that exist in other projects on market exposure and health (Dressler 2010). Three aspects of this wor k are key to its contribution. self sufficient and relatively wealthy as a group compared to other rural Bolivians, which limits market confounders: few feel compelled to enter the market if they do not want to. Second, most of the research and repeated panel measure ment s that control for endogeneity and cohort biases to improve causal inference (Godoy et al. 2009; Gurven et al. 2007; Gravlee et al. 2009). Third, the research is unique in testing hypotheses on economic and social variables th at have otherwise almost exclusive ly been tested in industrial settings. Yet, the drawbacks of the design have also led to valid critiques (Fisher 2003). Fisher points out that the econometric analyses used individualize all market exposure, disregarding its collective effect s on communities and cultures. The scattered results produced are also difficult to summarize into a cogent picture of community culture change. The risk of ganization,
82 In comparison to quantitative research, there has been little work on the emic how people choose to enter the market. In a potentially significant omission, the possibility of a non western Amerindian ontology has not been assessed (Vi v e iros de Castro 1998; 2004) . The theory of Amerindian perspectivism proposes a common ontology among many Amerindian peoples that sees exogeno us groups, spirits and some nonhumans as (Viveiros de Castro 2004:6). In this ontology it is the corporeal body that determines difference (not shared knowledge) and th erefore bodily variation is responsible for diverse animal (including human) behaviors. The one extensive treatment of ) is consistent with descriptions of Amerindian perspectivism though it does not specifically address the topic . For example, all things are understood to have souls and all animals to share similar cognitive capacities (Viveiros de Castro 1998; 2004) . Mythology explains that animals were once human beings and that some along with certain tree spirits and Sha man ( c c o ) can transubstantiate (Huanca 2008: 143). Furthermore, the spirit world is congruent with the human world but only accessible by humans through Shamanic ritual or dangerous circumstances such as sorcery (Huanca 2008: 118). Whether or not you a Amerindian ontology, its importance is an empirical question that must be evaluated in light of the significance of native metaphysics to social organization and meaning among lowland Amerindians (Maybur y Lewi s 2009). For example, it can shape what activities are adopted (e.g. trees with spirits may not be cut and sold but thatch palm for
83 roofing can be) and by whom (beliefs vary by generation, education, location, etc.). Even the meaning of, and reaction to, land grabs and encroachment can be affected grouped according to their origin, behaviors and appearance (e.g. Brincos are White foreigners and Qu llas are highlanders ). Issues of change are further complicated by perspectivism because adopting new becoming the other (VilaÃ§a 2007). Such a belief , if shared , would mean the transition from market ex posure to market integration is not just behavioral but existential.
84 Figure 1 1 . Typical chronic stress process model without explicit specification of culture.
85 Table 1 1 . Summary statistics from the epidemiologic survey including subsamples from the two ethnographic study communities. AjÃ ( n =37) Serrucho ( n =34) Total ( N =209) Systolic blood pressure 114.3 (11.0) 111.3 (11.7) 115.7 (15.3) Diastolic blood pressure 67.2 (9.7) 64.8 (7.9) 67.3 (9.1) Age, y 34.8 (13.4) 36.6 (15.4) 34.3 (14.2) Sex, % female 51.4 52.9 52.6 Pregnant, % 2.7 (0.2) 8.8 (0.3) 6.7 (0.3) Body mass index 25.3 (3.1) 23.6 (2.9) 23.9 (2.9) Education, y 4.6 (3.9) 3.3 (2.3) 3.3 (2.9) Spanish, (1 5) 2.7 (0.6) 1.9 (0.8) 2.1 (0.8) Depressive symptoms 22.8 (5.0) 21.5 (6.0) 21.5 (5.7) Cultural consonance in life priorities a 83.6 (8.1) 98.7 (8.6) 87.1 (10.0) Household size 6.0 (1.8) 6.6 (3.4) 6.0 (2.6) Monthly per person income and crops consumed, BOB 619 (669) 1870 (1890) 812 (1,090) Per person wealth, BOB 3,820 (4,107) 7,697 (6,138) 3,273 (4,243) Round trip travel time to market town, hrs 2 24 11.8 (12.3) Body mass index (BMI) = weight kg / (height m) 2; ; Spanish = self report of ability on a scale from 1 Not at all to 5 Very well; Depressive symptoms = Center for Epidemiologic Studies 20 item Depression Scale; CCLP = Cultural consonance in life priorities; Monthly per person income (PPI) = household income / number of household me mbers; Monthly per person wealth (PPW) = household wealth / number of household members.
86 CHAPTER 2 PERSPECTIVES ON LIFE CHALLENGES AND SOCIAL SUPPORT AMONG FORAGER HORTICULTURALISTS EXPERIENCING RAPID CHANGE: AN EXPLORATORY MIXED METHODS STUDY Overview The 2008 final report from the Commission on Social Determinants of Health of the World Health Organization marked important progress to make explicit the ultimate social causes of deprivation and poor health (CSDH 2008 ). The huge body of literature on which it is based demonstrates the importance of understanding the social determinants of health in order to address health inequity . The commission uses this base of work to build a conceptual framework to specif y important points of interv ention (Solar and Irwin 2007). The framework includes a category for the biases, n orms, and that they deem to be important structural driver s of health inequity (CSDH 2008 :42). The assumption is that if certain of t hese societal beliefs and expectations are changed , health can be improve d overall. The study of biases, norms, and values as social determinants frequently involves universalist measures such as population validated survey instruments that produce global estimates of prevalence ( Suppes 1974). These estimates are useful for determining how people respond to survey questions about such characteristics , but are insufficient for coming to understand them and for capturing the nuance and meaning in their varia tion from place to place (Bernard 2011). The focus on biases, norms and values also represents a potential threat to vulnerable populations who might be blamed for their own health inequity because of decontextualized findings about their shared beliefs an d expectations .
87 An alternative approach is to better contextualize the measure of local beliefs and expectations by simultaneously assessing the cultural determinants of health alongside social determinants . When I say cultural determinants of health, I am referring to those determinants that, for good and ill, imbue meaning and establish priorities in how we live our lives. Operationally , measuring cultural determinants can take the form of participant observation, open ended in ter views or quantitative evaluations that explore the everyday logic and meaning behind life priorities . Cultural determinants can also integrate data collected using different research modalities to iteratively build empirical measure that link issues like the chall enges people describe in their lives, the meaning of social support and resistance resour ces and health survey outcomes like biomarkers for psychosocial stress . Importantly, such an approach can also help to avoid blaming victims by giving a more complete accounting of a setting and its conflicting beliefs and expectations. M ethods based on cultural c onsensus t heory (CCT ) facilitate the construction and measurement of locally valid models of shared belief, knowledge and practice that do not rely on universa list assumptions (Romney et al. 1986) . Cultural consensus theory is based on cognitive anthropology that locates shared meaning within the minds of individuals. A common cognitive definition of culture is that which one must know to function adequately in a social setting (Goodenough 1996). From this perspective, then, the trick of measuring cultural determinants is to capture a consensus of shared meaning in a particular social setting and group that can then be compared against social determinants and hea lth outcomes at the individual unit of analysis (Bindon 2007; Dressler et al. 2005). This type of work is critical because sociocultural context has so
88 much to do with what it means to occupy a particular social place and even what things are locally consi dered to be challenging and supportive all critical components to health inequality (Marmot 2004). Cultural consensus theory requires that the meaning and importance of model components be empirically generated and then tested for salience . This can limit the population reach of any particular measure but can also reveal underlying mechanisms that link cultural meaning and significance to health outcomes (Weller 2007). One of the underlying mechanisms connecting sociocultural determinants to health inequality is the psychosocial stress process (Pearlin et al. 1981; Pearlin 1999) . Psychosocial stress in humans results from external or internal circumstances that tax or exceed the resistance resources available to a person (Lazarus 1966). A n a c curate assessment of psychosocial stress ors therefore requires an understanding of the social and cultural determinants of a setting and the group(s) to which individuals belong (McEwen 2009) . O nly when these parameters are known can we determine what it means to face a particular challenge or receive a specific kind of social support . E vidence also indicates that psychosocial stress occurs both within and outside of our exp licit awareness (McDade 2009) . So while challenges and social support are relative to local circumstances and often beyond the control of any one individua l , they are still endogenous to a learning and capabilities (Sen 1999). This state of contingency complicates measurement since we must simultaneously account for the personal and social in order t o accurately capture the contribution of meaning to variance in health outcomes . Despite the measurement difficulties , as Marmot and Wilkinson have argued, meaning
89 remains a critical determinant of health that requires more study to unpack its context depe ndent and relative nature (2003:9). Research on social support and psychosocial stress has been limited in scope outside of industrial societies (A dler and Ostrove 1999 ; Wilkinson and Pickett 2006) . Th e literature covers high , middle and low income countries but has not been widespread in non industrial settings (McDade 2009) . This leaves a gap in knowledge about the nature of social support and psychosocial stress w hen socioeconomic indicators like education, occupation and wealth are not the predominant determinants of health (Dressler 2010) . In this paper, I contribute to the literature on social support , psychosocial stress and health u sing a mixed methods design to explore how the rapid pace of recent change among a forager Bolivia, is affecting the meaning of challenges and social support. h because despite increasing overall levels of market integration during the last couple of decades , most communities are still quite inaccessib le and geographically isolated. This has led to a gradient in market exposure associated with levels of psychoso cial stress but largely unaffected by education, occupation, income and relative wealth (Nyberg 2009; Undurraga et al. 2010) . Previous longitudinal research has shown that aspects of life that usuall y contribute to inequality are n For example, c ommon stress buffers such as levels of social capital ( i.e. gifts and help with labor) are consistently high and occupational status markers do not matter because occupation rarel y differs from person to person (Godoy et al. 2007).
90 Research has also revealed that the wealth differences that do exist are not tied to a gradient in health ( Undurraga et al. 2010 ). There is, however, a social gradient importance in a community ( Reyes GarcÃa et al. 2008 ). Finally, the meaning of happiness has been shown to be quite distinct from what is ty pical in industrial societies. the shared cultural model of happiness and related behaviors was found to be focused entirely on social interaction and food security with virtually no expression of a connection between personal goals and happiness (Reyes GarcÃa and TAPS 2012:219). This distinctly social per spective on happin ess is matched in its uniqueness only by the extraordinary cardiovascular health profiles of this group. have some of the lowest measured levels of short term stress and stress related disease in the world ( Gurven et al. 2009; Gurven et al. 2012; Nyberg 2009; Undurraga et al. 2010 ). For the Tsimane, then, a focus on group happiness is accompanied by very little stress and chronic disease . What remains to be seen is whether these two phenomena can help to explain one another through an explicit connection . I n this study , I explore life challenges and social support among adults in two arket integration and exposure in order to pinpoint commonalities and differences in meaning during rapid change. The first part of the study relies on qualitative dat a from semi structured surveys t o investigate the salient aspects of experience that shape challenges and resources . I n these interviews I focused on (1) the most pressing difficulti lives, (2) the social and material resources available to deal with adversity and (3) the
91 local meaning of community and regional level social stratification. The second part of the study uses the cultural consensus measurement model to con struct and test a shared model of social support based on both the semi structured interview responses an d a separate ranking exercise. By combining these parts, I am able to deal with the mechanisms underlying meaning making for psychosocial stress and co nsider the impact of shared expectations as structural driver s of health inequity. Methods Research Setting tropical forests mostly along the Maniqui River in Jos Ã© BalliviÃ¡n province, Beni dep artment, Bolivia (Figure 2 1). back 400 years but it was not until the 1950s that a confluence of factors started to 1992; Metraux 194 2 ; Reyes GarcÃa and TAPS 2012). high rates of mobility between communities and, to a lesser extent, cross cousin marriage (Ellis 1996; Daillant 2003). Most a lso have high levels of autarky (i.e. economically independent self sufficiency) because they continue to produce their own crops and to fish and hunt in the rivers and forests of their territory ( Ringhofer 2010 ). The sustainability of traditional livelihood practices is increasingly under threat by external and internal forces. Outside encroachment by loggers and colonists and new national land redistribution laws are reducing available land, which thre atens a ll common food sources (Ringhofer 2010). Internally, population growth, due to improved overall health and well being and, in particular, reductions in infant and child mortality
92 are contributing to resource constraint in some areas . The result is increasi ng population density and decreasing per capita space for crops, hunting, fishing and gathering (Godoy et al. 2009). The increasing difficulty of self sufficient livelihood strategies has been slowly pushing more people to try to overproduce crops for sal e, to produce marketable products from the forest, to take on logging contracts or to do wage work such as clearing forest and planting pasture for non In the eleven years between the last two censuses in 2001 and 2012, the lation in JosÃ© BalliviÃ¡n province grew on paper at least by 244 % (from 3,614 to 12,442) while the total provincial population increased just 20 % (from 66,304 to 80,121; INE 2014 ). This has been due in part to real growth but also a shift in national identi ty politics that has opened a space for people to reclaim their indigenous status (Zycherman 2013) . The expanded indigenous population now represent s 42 % (33,86 8) of all residents in the province ( INE 2014 ). In 2010, this shift likely played a role in the has held in Bolivia. Participants Local schoolteachers in each of the two ethnographic communities provided me with the mo st current community censuses. In consultation with community leaders, I updated these lists to account for those who had recently moved away or recently arrived. Using these updated lists, in each commun ity I selected a purposive sample of 24 adults (aged 16 70 years) based on age group, approximate wealth (estimated by peers) and gender in two separate rounds of interviews (Table 2 1). I was careful to exclude residents who were away from the community d uring the period of research. I also selected a backup sample of 10 additional residents to use as replacements for
93 those who declined to take part. When a selected participant was unavailable on the first try I returned up to twice more to attempt the in terview. When participants were not located or they declined to participate, I would select a new person from the backup sample. For this study, the first round of interviews was semistructured and the second round consisted of structured ranking exercise s. Interviews were completed between January 2012 and March 2013 . I based sample sizes on measurement theory and empirical research on saturation in nonprobability samp ling for qualitative research (Romney et al. 1986; Guest et al. 2006). D ata from the sem istructured interviews was then quantitatively analyzed to build the rankings exercises used in the consensus analysis of the domain of social support (also see Chapter 3, Figure 3 3 ). The final semistructured interview sample includes 22 residents from A j Ã, the accessible community , and 24 from Serrucho, the remote community. The final sample of structured rankings interviews includes 33 residents from AjÃ and 36 from Serrucho . Residents (or their family members) that refused interviews commonly cited pr essing unfinished work in their fields or pending paid work that prevented their participation. I was not able to balance all sampling categories evenly, especially between the three age groups, due to a young average population in both communities. The s amples are therefore skewed some towards young adults but otherwise fairly evenly balanced in gender and wealth. Interview Design I conducted both rounds of interviews during the hours of 8am and 8pm. I homes, which only sometimes have walls, most interviews were conducted outside of
94 the home and in front of other household members and visitors. Whenever possible I asked interviewees to sit with me away from others. I also tried to schedule my visits for a time when others would not be around or in a location nearby but not at the rs and distractions. For the first round of interviews I chose an open ended, semistructured format to allow participants to highlight areas they deemed important within the loosely structured interview guide (Bernard 2011). This allowed me to maintain con sistency throughout the interviews while still providing ample opportunity for the discovery of novel themes and topics. Semistructured Interviews . I designed the interview guide to give participants the opportunity to teach me about the challenges in thei r lives, what they mean for them personally and what it takes to deal with them . I chose to first focus on difficulties because in participant observation I noticed that most people had a lot to say on this topic. The topic of difficulties led naturally in to the types of resistance resources people relied on to deal with problems including social support. Next, I would steer the conversation to how ongoing changes in the community have led to new p roblems and new opportunities. Lastly, I explicitly explored the topic of social stratification to income, wealth and occupation. Social Support Rankings . I used responses to questions about problems and resistance resources to create meaningful ranking exercises that I carried out in a new round of structured interviews among a fresh sample of p articipants (Table 2 2; also see Chapter 3 ). Due to high illiteracy rates among participants I used laminated photos of locals as examples of each of the sources of help (see Figure 3 2). I asked
95 r espondents to rank their three most important sources of help for each of ten problems . The sources of support that were not ranked by participants I assigned an average score of the remaining ranks [(4+5)/2=4.5 each]. When respondents reported just one or two sources of support for a problem , I gave the remaining sources an averaged score of the remain ing ranks [e.g. (3+4+5)/3=4 each]. In this way , all 50 possible problem/support dyads (e.g. one dyad was interfamily problems/support from community leaders) had scores to compare . Analysis I audio recorded all 46 semistructured interviews and made verbatim transcripts following standardized guideline s (McLellan et al. 2003) . I then imported interview transcripts and note s into MAXQDA10 software (VERBI GmbH, Berlin, Germany), which facilitated both word frequency and theme based analyses (W utich and Gravlee 2010) . I examined word frequencies for the entire sample , and separately by community, to identify potential themes. T hrough careful reading of the text, I further examined high frequency themes to determine their relative salience (Ryan and Weisner 1998). Then, I created my coding system while reading the verbatim texts looking for common meaningful themes. I focus ed on what was emphasized , how different ideas connected and on differences of opinion for respondents within and in between c ommunities. To triangulate and confirm themes I used searches for linguistic connectors or like that ; Ryan and Bernard 2003) . I determined key sources of social support and problems from a frequency analysis of items mentioned in semistructured interviews. These top problems broadly included both physical and mental health, personal and social relationships and material resource concerns. I analyzed the rankings data using cultural consensus analysis in
96 AnthroPac and UCINET software by Analytic Technologies (Borgatti et al. 2002). Finally, I used the informal model of cultural consensus to accommodate my interval data. Results Se mistructured Interviews I have stratified the themes from semistructured interviews by community and organized them into three sections : (1) difficulties and change , (2) resistance resources and change and (3) social stratification and change . Table 2 3 su mmarizes the most salient themes for each section . Aj Ã : An Accessible Community Difficulties and Change Family h ealth . , with care for young children and the elderly being a particularly serious conc ern. The need for money to find transport for the sick, pay for doctor visits and purchase medicines was quite pressing. One elderly woman said, I worry about my husband when he is sick and I have to look for someone to borrow money from to buy medicine so he can get better. (SSA09) Residents of the AjÃ community vastly preferred biomedicine to traditional forest medicines that few knew about and even fewer were willing to travel to find in the dis tant forests. Interestingly, a large proportion of respondents preferred to go to a nearby Camba Camba is the collective identity adopted by the descendants of European colonists in lowland Bolivia) who is otherwise not a trained docto r Don RÃos. Don RÃos provides both diagnosis and treatment of illnesses. The explicit reasons given by many respondents for their preference of Don R Ãos includes
97 his quick diagnoses, reasonable prices, willingness to give drugs right away, to advance peop le drugs before payment, and acceptance of barter payments. Maintenance of f amily a gricultural p lots . Crops were nearly as prominent as AjÃ about the most difficult challenges in life. A large part of this concern cam e from the uncertainty involved in their care. With population growth and encroachment by colonists, priorities of access to schools for children have to be balanced with a need to protect crops from flooding near the river and from livestock entering the fields (Figure 2 3 ) . This has led to fields being planted having plots nearby in the past saying, We lived really far away before. Really far away. Two or three kilomete rs from the village. And we could have our livestock and there were no problems between neighbors because everyone was so far away. Now we live very close. Before it was all forest. (SSA10) Finding w age w ork . The third key concern for residents in AjÃ was the search for wage work. Consistent with other major life problems, the search for work was made worse by its extremely unpredictable nature. Even when someone found work they had to be leery of agreeing to extended contracts with a small advance becaus e so many workers have been denied some or all of their final pay once a work contract is complete. A leader of the community explained, They are going to, let's say, use their strength to do the work and then when they the boss, the like that, it's something, a deception. (SSA05) When this occurs workers have little recourse for claiming their wages as most of the contracts are verbal and th e disputes come down to their word against their wealthy
98 and powerful employers. This leads most workers to choose lower paying daily work with no guarantee of future earnings but little risk of exploitation. Resistance Resources and C hange More c hildren and l ess e xtended f amily . Improved access to vaccination campaigns, regular and emergency medical treatment and school lunch programs have dramatically reduced child and infant mortality as a function of distance to San Borja (Gurven et al. 2008) . The increased number of children that survive past five has led to rapid and skewed population growth in AjÃ . Combined with the smaller size o f extended family networks due to most families being relatively new to the area, parents in AjÃ are straining under the demands on their time. One young mother lamented, I take [the children] with me to the field and it takes a lot for me to manage all [f ive] of them. (SSA08) With no one else to care for them, mothers and fathers frequently have to take their young children far off to the family agricultural plots. Education . The constant travel by young men in search of work and their frequent relocation to other towns for education has led to a fraying of community and ns where they attend better or more advanced schools. This results in a huge drain on resources for the families who have to supp middle aged father explained it, It's difficult to support them, to buy their food. I work hard to take care of my sons and sell my rice for their trips, for their food. All of that, r ight? So I feel like these are the [most difficult] things. (SSA05) It also exacerbates a serious gender inequality for women. Few young women get the opportunity to study elsewhere with an average level of education and because
99 they stay behind, their cha nces of ending up with a partner who is well educated may be lower as well . Increased l ivelihood r isks . There are a few residents in AjÃ who have managed to successfully make money in logging, risky resale businesses or by qualifying for a job due to education or unique skills often learned from missionaries or research projects. For this lucky few, they can afford to own motorcycles or t o purchase cattle and try their hand at ranching. They can also more easily afford to send some of their children away to be educated. As it stands, however, these families are the exceptions. Most people who risk giving up their agricultural plots to tak e on long contracts or start businesses, fail. A middle field of a Camba said, There isn't much food. There isn't any. So I have to look for food from the community to eat. (SSA09) The fa milies of wageworkers reported more struggles due to a dearth of available social and natural resources to fall back on. Social Stratification and C hange G ender i nequality . Women in AjÃ are being saddled with more burdens while having fewer social support resources. A mother of 12 children expressed her dismay at I worry about helping [the older ones] so that they will come visit me so I can s ee them . But they don't always want to listen to me. T hey already think differently. [The younger ones] don't want to listen to me either. They want to [ go ] somewhere else. To work or to live somewhere else. (SSA07) Adding to this burden is a perspective on the part of many men that their wives should have as many children as they prefer. A father of five said , only partly in jest , that he would like 220 children while he acknowledged his wife did not want any more
100 children (SSA02). None the less, there h as been some effort to increase the recognition and power of local women. Two years ago a young mother was elected as the first Presidenta Increased e xposure to r acism . Members of the AjÃ community have many more encounters with non minute bus ride away. On weekends, minibuses come directly to the community to take residents to nearby Yucumo. Encounters also occur in the community it self, which has constant traffic accessing its river port where most farm products, hardwood and roofing panels from up river are offloaded. A young man who speaks fluent Spanish explained what he has experienced saying, Yes, [people in town] say . (SSA04) Another young man, a father, expressed how he planned to address this saying, Now I think about how my kids. T o [have them] study, educate them. I want to educate my kids like, like the Cambas, like the people tha t live in town (i.e. San Borja) . (SSA01) Continued e xploitation . AjÃ are rarely the owners or buyers of resources and products. Instead, they usually work as producers and caretakers. For example, there are a fe w community members who use community land to care for the cattle of non the community is easily accessible from the highway. Others warehouse roofing panels near the river port for non merchants who buy the panels piecemeal over time and then transport them in bulk to the city of Santa Cruz in the south of Bolivia for resale at a 50 100 % markup. There is also manipulation of community members for municipal projects that require community approval before funds are di sbursed to officials. An elderly resident shared,
101 There are some that don't work, like in City Hall, they make money easily because they steal money in the name of other Tsimane'. Like they promise projects and never do them. It's the fault of the bosses , they're the ones that are stealing money. It's the great council's fault. (SSA10) According to community members, once approval is given, the projects are only sometimes begun and they are never finished. Instead, the money disappears. Most blame this on corrupt government officials and some blame it on the GCT itself. There were goals for those projects but, but now there isn't because it's pure lies and also, what the p rojects do, they never appear. T hey just spend the sum of the money and then nothi ng happens. (SSA02) Serrucho: A Remote Community Difficulties and C hange Family h ealth . Respondents reported difficulty in treating common illnesses but in particular emergencies that required evacuation to a clinic such as high fevers or severe vomiting in children or injuries and accidents among adults working with chainsaws and felling tre es. Related to this issue was the availability of rapid transport, which is now all privately owned in the community ever since the last collectively purchased community outboard motors stopped functioning a couple of years ago. Family was usually the fir st and last resort for finding treatment including forest medicines and spiritual healing. Most people reported a preference for biomedicines when they were available and there was money or credit to buy them. Despite the preference for biomedicine almos t all households retained some knowledge and practice in the use of forest medicines. This included mostly common medicines like a tree bark used to make salicylic like tea , similar to how Aspirin can be extracted from Willow bark. Residents also describ e various bouts of illness from forest spirits that required diagnosis and healing from people with knowledge of the old
102 shamanistic methods including use of the Qurpa ( known among Aymara highlanders as a Millu ; Qurpa Q ullpa , though this is actually the name for saltpeter, a different substance; Ellis 1996). Severe sickness, however, often requires more knowledgeable practitioners. Yes [the qurpa] works when the sickness is not really serious. If it's really serious it doesn't work well. My mother in law is really good at treating the sick with it. S he always treats my sick children. (SSR12) Dwindling n atural r esources . Another common problem reported by residents was the increasing difficulty of finding land near the co mmunity for their agricultural crops that was still productive, would not easily flood and was not threatened by invasion from nearby livestock. They also had trouble finding the palm fronds ( ) needed to produce roofing panels for sale and trade to merchants. The combination of these two factors created much uncertainty and struggle for many families. My neighbors even took to preparing their agricultural plots several travel upriver and would leave for weeks at a time to tend those fields a practice only possible because they own ed a canoe motor. An elderly resident described the threat, explaining that her rice crop was partially eaten by pigs, T his year what happened, I had planted rice and the, the pigs came and ate it and I couldn't pick all of my rice. (SSR08) There are also long standing fears that a particularly wicked spirit who punishes even small transgressions inhabits the forest on the opposite side of the stream near the southern bound ary of the community (Figure 2 4 ). This was reinforced for many during my time in the community after a series of river stingray attacks occurred in the stream during the dry season. There is also a patch of rapids on the river just north of the community where a handful of people have died, incl uding a student struck by
103 light ning. People say this occurred because he traveled at night and disobeyed his different father recounted, They were returning and were almost to [a nearby town] and it was getting cold. [The s on] said forcefully to his father that he [wanted to continue] , and his father said let's sleep here on this bea ch . A nd the young man didn't want to, so w hen it came a cold front a strong thunderstorm attacked him, the young man , and it killed him. A light ning bolt. (SSR04) Social p roblems and g ender d iscrimination . There are many reports of disquiet between families in the community. This is the explicit reason often given for why there are nine or so distant clusters of homes and not just two or three. A poor resident explained his experience with this undercurren t of distrust, They had said that I didn't help, didn't work... the firearm that I have, the shotgun , I bought fr om the teacher. So the other [guy] , without knowing, without being familiar with the situati on , he had got into it with me. He knew it was already paid for it . (SSR03) Actual transgressions can be punished by the supernatural, even when committed by children. A father described how his son was struck ill for thievery, There were some fruits, watermelon , that belonged to another person. My son had taken them, had gathered, well, stole them. He fell sick for two weeks because he had done evil. (SSR06) Several women also reported being forced into marriages by their families that made them physically sick. One young woman, the second wife of her current husband, attributed a months long illness that occurred after her marriage to evil sent her way had been opposed to the marriage herself but was forced into it by her family. My sickness that happened was fault because he left that, that woman that he had, right? And she was so mad against me. She cursed me. (SSR02)
104 A middle aged woman who was the eldest of three sister wives recounts a similar story about her current husband, I didn't love him but he loved me so he kidnapped me and we lived elsewhere for three months. And after I returned I wanted to leave him but [he] didn't want to l eave me, he wanted to keep living with me. (SSR12) Resistance Resources and C hange Transportation . Newly available, low cost, low power, long tail outboard canoe motors known as pekes (or peke pekes for the sound they make ) that can be easily moved or remo ved for safe keeping, are currently transforming transportation on the Maniqui. During my first visit to Serrucho in 2010 there were just four canoe motors, two large outboard motors and two pekes . By the start of 2013 there were at least 12 pekes . Reside nts report that the motors use less gasoline than the previous models and they are making redesigned dugout canoes with increased length and decreased depth to better suit them. It all adds up to easier river travel and increasing desire for even more pek es . An elderly mother of a large family weary of the days long journeys to and from town without a motor shared, I want a peke . To take my products to market. (SSR02) Her sentiment is shared by most community members who consider buying a peke a substanti al and important goal. When combined with increased incomes now available to people logging upriver, the spread of pekes is likely the harbinger of dramatic new market exposure untethering people from the inaccessible isolation of the past. Help for p ay . The rapid shift in livelihood approaches among many families has work loans given by employers or buyers. These loans have become critical to
105 sustaining families since workers o n contract cannot help maintain family agricultural plots. A knock on effect of this shift has been a change in the long standing tradition of intra and inter family work exchange during harvests and for other large projects, such as erecting a new house. Many families who continue with agricultural plots now report that they must pay for assistance to harvest their crops and when they do not have the money, crops get left in the fields. When I have lots of work, then yeah , I ask people so they'll help me. But I have to pay cash money. (SSR03) Increased l ivelihood r isks . Like AjÃ , residents in Serrucho also report novel risks to their livelihoods. Most of these risks center around the difficulty of maintaining traditional agricultural plots in an increasi ngly challenging environment. They also have to do with the effort required to gather supplies for making products like roofing panels another key source of income in the community. The problems are attributed to various sources but in particula r, increased population density and increased numbers of people raising pigs and cattle that eat crops. The situation also reduces the number of people willing and available to help each other. Some residents seemed resolved to an eventual collapse of logg ing , which they hoped would result in a return to the old ways. I think that the people in wood (logging), I think they don't see, realize, that they're cutting down [all] the trees. I think that you won't see any more afterwards. That will happen. When t going to have the money either. (SSR03) Social Stratification and C hange Logging . Income levels in Serrucho have begun to diverge dramatically between those families whose men work logging contracts and those who do not. This new
106 source of income and the material purchases it allows is enticing others to take logging contracts as well. A young wife expressed the advantages and disadvantages succi nctly saying, T he people who have mon ey, have valuable things because they work with wood ( logging ). We are laid back because we don't work [on contract] . do it later, not no w. , that Some residents fear the worst from this growing trend including retribution from the forest itself. One middle aged resident who has shunned taking on his own logging contracts explained that a spirit had punished him for damaging a tree while hunting. I had gone to the forest, saw an animal and shot an arrow. And my arrow stayed up there in the branch so I cut that branch down. It fell to the ground and from evi l from the spirit o It attacked me like I had someone shooting arrows (indicates in his side) in Another elderly resident predicted a poor outcome from all of the logging. When asked why incomes were diverging he said, Because they work with wood, that's why they have the cash. They buy motors (for canoes), they buy chainsaws. They work with the wood. When the wood is gone, t hey're going to be poor, they're going to suffer. (SSR04 Income i nequality . Income ineq uality is most visible in the material goods that some can afford and others cannot. It also affects who has the best access to outside resources because those with money have pekes and gasoline for travel. Cross cultural income inequality is becoming mor e and more apparent to those who take logging contracts. They hear how much more the buyers are making than they are and conclude that these outsiders are taking advantage of them. A young husband who had just started logging said,
107 For example , from one f oot of wood the buyers resell at 5 Bs, right. They buy from us at 2.50 Bs. T hey make [even] more when they sell it in La Paz ! (SSR09) they take out work contracts with buyers to obtain a cash advance, which must be paid back in feet of timber. This debt peonage is exploitative and shifts all risk for the quasi legal permission from the GCT, if the forestry service deems their timber illegal and confiscates it, no one compensates the contractors for the loss. Instead, the outside buyers continue to hold that debt over the workers who may also face legal penalties. Outsiders . Serrucho has a long history. It is mentioned by name in the written record going back over 100 years ( NordenskiÃ¶ld 1915 ). Despite its long exposure to outsiders, though, it has remained mostly insular. There is a high rate of cross cousin marriage between famili es and several families who still practice polygamy with sister wives. There is also a wary attitude towards outsiders who are generally welcomed as visitors but not as new residents, unless through marriage with a community member. Traveling merchants hav e a particularly bad reputation. An elderly sister wife was blunt about this suspicion saying, If someone comes from outside, that (SSR06) The semistructured interviews reveal some overarching ideas that crosscut the themes discussed in the results and speak directly to issues of relative status and psychosocial stress. I discuss these in three parts below, (1) risk and uncertainty, (2) less time and new demands and, (3) discrimination and exposure.
108 Uncertainty The unp redictable nature of achieving life priorities led to daily distress for residents of both communities. However, this uncertainty did not entail just the search for basic material needs, it also included taking on new risk. Some of this was by necessity d ue to the depletion of wild game and fish. Other risk was pursued by choice in order to strive for new priorities. Such goals were more explicit in AjÃ. People wanted more education, to get better jobs and improve their lot. In Serrucho people just gener ally wanted more money as a means to security to maintain their lives without having to leave and give up their kin networks. More money represented the security of better transportation through the purchase of peke canoe motors, gasoline, livestock and ca sh in hand to pay for clinic visits. Less Time and New Demands Many respondents observed that sharing resources and exchanging help between non family members does not happen much anymore. This seems to coincide with changes in the nature and type of reso urces available to people. Most adults now do some type of work for money or trade in order to meet the most basic needs of their families, especially for medical services, fishing/hunting/farming supplies and clothing. The increasing scarcity of natural resources due to less habitat (logging) and more fishing/hunting (increased population) also matches the extent of local labor transition s . That is, the less forest there is available, the more likely people are to seek wage work. The corollary reductions of social support and increases in food insecurity are reported as constantly worrisome.
109 Rankings of Problems and Social Support Respondents strongly share d a c ommon model of social support. T he Eigen value ratio of the latent firs t to second factors was 11.4:1. The first factor also accounted for 88.2 % of the variance between people. Average knowledge was high at 0.81 (Â± .08) and the standard deviation statistic met criteria set for the formal consensus model based on sample size, number of items and aver age knowledge (~.14 ; Hruschka and Maupin 2013) . The consensus analysis o f the rankings exercises revealed that family is th e key source of social support. Figure 2 2 shows that family was ranked first over all for 9 out of 10 difficulties. Family even ranked higher than community leaders for the category of community problems (Family=3.8 3 and Community Leaders=3.95). For the category of health problems, family ranked just behind health professionals at 3.53 versus 3.17, respectively. Support sources of secondary importance varied more than first choices. Three other sources were important for at least one problem. Specifically, friends were more highly ranked for dealing with sadness, lack of work a nd lack o f transportation. Community leaders were highly ranked for community problems but also for inter family problems and taking care of children. Respondents cited teachers as important community leaders, which is why they were also considered important as res ources for taking care of children. The last highly ranked secondary source s of support were health professionals for help with a lack of money. This can be explained by the presence of informal healers and biomedical nd non who accept trade and cre dit for treatment and medicines, sometimes even dispensing these for free. Finally, outside groups did not rank as important sources of support for any challenge .
110 R espondents reported that few social support resources beyond family, as defined in the semistructured interviews, ar e regularly available to them. Health problems and material concerns dominate the list of life problems but outside of family and health pro fessionals, there are few strong sources of support. Instead, friends and community leaders only get mentioned as sometimes useful and this is only (GCT; Great Tsim Governmental Organizations (NGOs ) and the regional government were not mentioned as strong sources of support. Discussion The purpose of this exploratory study was challenges, soc ial support and resistance resources i n the context of rapid change. These topics are all key to building an un derstanding of the stressors and resources . Below I discuss the two sets of data presented , (1) qualitative data from semistruc tured interviews, and (2) results from the consensus analysis of social support . The common finding from both data sets is the central , and often exclusive, role of family as social support against life stressors . As demonstrated clearly in the consensus r esults, family is critical to addressing life challenges as diverse as sickness, maintaining child well being, food in security and various types o f social conflict. The qualitative data further shows the complexity of this socially patterned support. For e goals and consequences in the two study communities. An emphasis on child well being through education has driven new families to settle in AjÃ and within a short distance of the local school. Parents would frequently mention education as their strategy for improving the
111 live of their children. A quick comparison of the geographic distribution of community households (Figure 2 3 and 2 4 ) also demonstrate the premium placed on locating ne ar the school in AjÃ compared to Serrucho . Well being and future security for children is approached with a different logic in Serrucho . P arents there have continued with the practice of cross cousin marriage to try to insure future social stability by em bedding their children in strong social kin networks. More than that, paren ts from different families commonly arrange future marriage s between children and sometimes even between just two sets of cousins so that kinship connections becomes tightly cross s titched family to family . This is the opposite of current marriage practice in Aj Ã where arranged marriages are generally frowned upon and almost every household has at least one parent who is not closely related and from outside of the community . Overal l, people in Serrucho also seem to define their need for social support in more traditionally communal and less person al ways. This means that it is not uncommon for an entire extended family to be considered when making important decisions about where to live, who m to marry and whether or not to do wage work . In the case of the two women who were forced into marriages by their families, the local preference for family well being ahead of personal well being re su lted in great personal strife. The fact that the ordeals remained painful enough for each of the se women to share with a non outsider a taboo action attests to the severity of suffering . Combined with the gender inequality other researchers have identified throughout seem s likely both psychosomatic symptomology and idioms of distress (Nichter 1981) .
112 My study builds on cross cultural status research in three ways . First, I present systematic evidence regarding the uniqu e conception of challenges and resources among a non industrial society of forager horticulturalists undergoing rapid change. In particular, my findings suggest that keen awareness of the resources they lack in comparison to other Bolivia ns , though the ir priorities and approaches varied between the two communities. Aj Ã with more market exposure express ed preferences for solutions to their problems that are more similar to the patterns found in the rest of Bolivian society such as looking for wage work for income and prioritizing school for their children . T hose with less exposure in Serrucho , however, express ed a desire for money as a means to maintain their culture, not change it . This is exemplified by an almost u niversal desire for small peke canoe motors that allow people to continue residing in their otherwise remote village while still enabling access to the market , clinics and other resources up and down the river on their own terms . N ew life uncertainties and demands in both study communities also highlight the importance of social and resource security to social support priorities. A t the individual and family levels, for example, respondents were very focused on maintaining what they could of their social su pport networks while pursuing more material security and improved health. Finally, my study highlights the role of gender and racial discrimination among sources of psychosocial stress. Despite the prominence of discrimi interactions with other Bolivians, there has been no epidemiologic research on the health effects of discrimination among this population. For context, a search of the
113 literature in Web of Science in May 2014 brings up 165 results for Tsimane* and Chiman*. Adding discrimination, racism or exclusion brings th e total down to zero. F to Bolivian society and the intensive r esearch presence among this population that has so far produce d more than 165 unique academic articles, tens of dissertations and countless other research products in less than 20 years. Limitations I acknowledge limitations of the study design. I am unable to assess whether residents who agreed to participate differ systematically from those who refused. Also, my focus on just two communities in the qualitative analyses limits my ability to generalize to other parts of the population or to explore in more detail how perspectives might vary throughout the population . Despite these limitations, this study contributes new insight into the current challenges, resistance resources, life priorities and sociocultural processes that shape relative deprivation . Future efforts to explain and reduce psychosocial stress will be strengthened by incorporating a better understanding of priorities and perspectives, as well as the larger influences across multiple levels of analysis on the construc tio n of social status.
114 Figure 2 1 . Map of in J osÃ© BalliviÃ¡n province , Beni department, Bolivia.
115 Figure 2 2 . Consensus ranking of sources of social support for the top ten life problems ( N =69 ). Problem Sources of support Family Friends Community l eaders Health p rofessionals Outside g roups 1. Health problems (personal and family) 1.8 4.0 4.1 1.6 3.6 2. Taking care of ( grand ) children 1.0 3.4 2.9 3.8 3.9 3. Crops and food 1.0 3.1 3.4 3.8 3.7 4. Lack of money 1.3 3.5 3.8 2.7 3.7 5. Sadness 1.2 2.4 3.5 3.9 4.0 6. Problems with spouse 1.3 3.2 3.1 3.8 3.8 7. Other problems with family 1.7 3.0 2.4 4.0 4.0 8. Lack of good work 1.3 2.6 3.5 3.8 3.8 9. Problems in the community 1.9 3.0 2.0 4.1 3.9 10. Transportation 1.1 2.9 3.5 3.8 3.7 Mean 1.3 3.1 3.2 3.5 3.8 Rank of s ources 1 st <2 nd 2 nd <3 rd 3 rd <4 th 4 th
116 Figure 2 3 . Map of Aj Ã ethnographic research community in J osÃ© BalliviÃ¡n province , Beni department, Bolivia. Households are indicated by orange circles and sized by number of household members.
117 Figure 2 4 . Map of Serrucho ethnographic research community in J osÃ© BalliviÃ¡n province , Beni department, Bolivia. Households are indicated by orange circles and sized by number of household members.
118 Table 2 1. Purposive life stage samples of semistructured interviews in accessible (AjÃ) and remote (Serrucho) communities. Accessible c ommunity ( n =22) Remote c ommunity ( n =24) Combined c ommunities ( N =46) 16 34 years old , % 46 38 41 35 49 years old, % 32 25 28 50 years old, % 23 38 30 Female,% 46 50 52 Less wealthy, % 50 50 50 Table 2 2 . Purposive life stage samples of rankings interviews in accessible (AjÃ) and remote (Serrucho) communities. Accessible c ommunity ( n =33) Remote c ommunity ( n =36) Combined c ommunities ( N =69) 16 34 years old, % 55 36 45 35 49 years old, % 24 33 29 50 years old, % 21 31 26 Female,% 52 53 52 Less wealthy, % 49 53 51
119 Table 2 3 . Summary of key themes from semistructured interviews on life problems, resources and social stratification by ethnographic community. AjÃ Serrucho Difficulties and change Family h ealth Family h ealth Agricultural p lots Natural r esources Finding w age w ork Social problems Resistance resources and change More c hildren, l ess h elp Transportation Education Help for pay Increased l ivelihood r isks Increased livelihood r isks Social stratification and change Gender i nequality Logging Exposure to r acism Income inequality Continued e xploitation Outsiders
120 CHAPTER 3 MARKET EXPOSURE, CULTURE CHANGE AND INTRACULTURAL DEVIATION IN LIFE PRIORITIES AND SOCIAL SUPPORT: AN EXPLORATORY STUDY FROM LOWLAND BOLIVIA Overview The material, social and health factors that impel and entice indigenous peoples to integrate into market economies have been extensively investigated and tied to the development of social gradients in health (Baker et al. 1986; Berry et al. 1986; Spindler 1984; Godoy 2001; Steffen et al. 2006; McDade and Nyberg 2010). This stream of literature documents changes that typically accompany the process of market integration. These include shifts in individual behavior such as dietary habits, physical labor, lei sure acti vities, social interaction and consumption of commodities (Siskind 1973; Hugh Jones 1992; Fis her 2000 ). Studies of broad economic and social changes further show that local cultural norms are subsumed but not replaced by new regimes (Appadurai 2001; Lu 2007; Tsing 2007). One proposed mechanism to connect shifts in livelihood to social gradients in health is the psychosocial stress of status incongruity. Status incongruity occurs when established meanings of status conflict with new meanings lea ding to novel forms of inequality for those who cannot balance conflicting demands (Baker et al. 1986; Bindon et al. 1991; Dressler et al. 1996). For societies in transition, those who can best equalize established and emergent indicators of status have be en shown to have better physical and mental health (McGarvey and Schendel 1986 ; Dressler et al. 1996; McDade 2001). Severe social gradients have also been linked to worse chronic disease outcomes through intensified status competition and decreased social support for
121 humans and other primates (Townsend and Davidson 1992; Sapolsky 2004; Wilkinson and Pickett 2007). At the early stages of market integration, the importance of socioeconomic status (SES) markers compared to other forms of social status is less clear. (i.e. market independent and self sufficient) small scale society, indicates that community wealth rank and community wealth inequality have little to no impact on health (Undurraga et al. 2010). Howev er, ascribed social rank plays an important role , at least among men (Reyes GarcÃ a et al. 2008). While cultural models of status and social support have elsewhere been studied within groups in the latter stages of market integration this study focuses on a group of forager horticulturalists from lowland Bolivia still in the early stages of market integration (Gurven et al. 2012) a gradient of market exposure in communities locate d along the Maniqui river with those farthest upriver having the lowest exposure (Godoy 2001; Byron 2003; Gurven and Winking 2008). My study leverages this proxy to explicitly test cultural models against market exposure including two primary research ques tions related to culture change: 1. Has community level market exposure led to shared or separate cultural models of life priorities and social support? 2. Is the re systematic deviation within the models of life priorities and social support base d on e x p o s u r e in their community of residence ? Methods I conducted semistructured interviews, free list exercises and ratings/rankings surveys during 2012 and 2013 with 46, 45 and 69 permanent residents, respectively, from two indigenous (Table 3 1 and Figure 3 1) . The free list exercises and ratings/rankings were used to construct and test cultural consensus
122 models of salient domain s of culture. Cultural consensus analysis is an inverted factor analysis used to test levels of agreement b etween participants who are weighted according to their demonstrated expertise in a domain of shared knowledge (Romney et al. 1986). I t is based on c ultural consensus the ory , which locate s shared meaning within the minds of individuals as a way to capture both individual and gr oup characteristics simultaneously . Both study communities are located in the tropical forests along the Maniqui River in Beni Department, lowland Bolivia. The relatively accessible community , AjÃ, is set along a rural highway about 20 minutes east by veh icle in good conditions from the nearest market town, Yucumo. The remote village , Serrucho, is reachable only by canoe, which takes 3 4 days traveling up river sans motor and one one half days by motorized canoe depending on river depth and weather conditi ons . The differences in market proximity result in varied levels of influence and options for market participation. These include availability of day labor on ranches, logging contracts, quality and frequency of schooling and teachers, free and paid clini cs, and visits by merchants looking to buy or trade for forest products and farm crops. I selected participants for each stage of research through life stage purposive sampling to maximize variability by age group, gender and estimated wealth known to freq uently be important to knowledge and belief in the measurement of cultural domains (Handwerker and Wozniak 1997). I conducted semistructured interviews and free lis t exercises with adults aged 16 70 years. For the ratings/rankings sample I expanded the age range to include adults aged 15 75 years to capture additional variation and better
123 between 14 and 20 years old. Rankings I analyzed a combined total of 46 semistructur ed interviews for the most frequently mentioned life problems and sources of support (22 from AjÃ and 24 from Serrucho ) to create the rankings exercises for the cultural consensus analysis (CCA) of social support. The CCA interviews lasted about one hour a nd I conducted the m separately from the free list exercises. I audio recorded and transcribed interviews for theme analysis and later calculated word frequencies . Using this data I determined the ten most common problems and the top five sources of socia l support based on both frequency and the importance placed on each by interviewees. Examples of common problems include family health problems (1 st ), sadness (5 th ) and transportation (10 th ; Table 3 4) . Examples of sources of social support include family (1 st ), local officials (3 rd ) and help from outside the community (5 th Due to high illiteracy rates among participants I used laminated photos of locals as examples of each of the sources of help (Figures 3 2 and 3 3 ). For each of ten problems listed I asked respondents to rank their three most important sources of help . The sources of support that were not part of the top three I assigned an average score of the remaining ranks [(4+5)/2=4.5 each]. When respondents reported just one or two sources of support for a problem I gave the remaining sources an averaged score of the remaining ranks [e.g. (3+4+5)/3=4 each]. In this way , I was able to score all 50 possible problem/support dyads (e.g. one dyad is interfamily p roblems/support from community leaders) .
124 Ratings I collected 21 and 24 free lists in AjÃ and Serruch , respectively, representing 30.4 % and 21.6 % of the eligible populations. I collected f ree life priorities among respondents. To complete the free list exercise, I required between 15 40 minutes. I asked the same elicitation question to a ll participants f or the domain of life priorities, which translates as good life I also used follow up prompts for additional things and people most important to a good life when respondents themselves did not otherwise exhaust these categories with at least 20 items . I recorded all items in a notebook during the exercises and entered each into a combined dataset for analysis. helped me to confirm and combine disparate responses that described the same or similar items before I combined them into common items . I then calculated f requencies from my combined dataset. In total, participants identified 292 unique items, 57 of which were named by ten or more people each (Table 3 2) . To create the ratings exercises for the CCA of life priorities I graphed a scree plot 2 6 th item. T went y two of these 26 items were high frequency (mentioned by over half of the respondents). The remaining four items and two additional items from the free lists I had observed to be important were included as medium frequency items mentioned by 50 25 % of respondents. Finally, eight l ow frequency items (mentioned by less than 25 % ) were included to help insure the accuracy of responses and resolution of analysis . Participants rated items on a scale from 1 ( it at all ) to 5 ( need it ). To attenuate automatic or ac quiescence bias I reversed scales for half of the questions
125 and followed up with participants when responses were counterintuitive (e.g. a father who pays for his son to attend high school in another community but says he does not value education). Consens us Analysis In total, I completed 33 and 34 ratings/rankings exercises in AjÃ and Serrucho , respectively. I performed CCA of the ratings/rankings with AnthroPac and UCINET software by Analytic Technologies (Borgatti et al. 2002). Due to my use of interval response data for the ratings/rankings exercises, I chose the informal cultural consensus model (CCM) for analysis . To help characterize systematic variation along the second factors of life priorities and social support I calculated individual deviation scores. I did this for item ratings and rankings by subtracting their scores from the cultural answer key. I then averaged these deviation numbers across each community sample for a content comparison. For inclusion in the analysis of d eviation in life priorities I used a natural cutoff determined in a scree plot of absolute ratings/rankings values 5), for a total of 13 items. ifference in the analysis of deviation in social support. Results Cultural Consensus Analysis: Life Priorities My analysis of 45 free lists resulted in a ratings exercise with 38 items of varying importance . The 69 community members that rated the final l ist of 38 life priorities demonstrate a moderate degree of sharing within the first factor of knowledge (Table 3 3) . For example, the ratio of the first to second Eigen vector values is 4:1, surpassing the recommended cut off of 3:1 (Romney et al. 1986). This first factor also accounts for
126 72.7 % of the variance between people. T he average knowledge of raters is 0.63 ( Â± .12). The standard deviation statistic is also below the suggested cut off for a shared domain proposed by Hruschka and Maupin (2013) based on sample size, number of items, and average level of knowledge in a formal model (~0.14). However, the ratings/r ankings I use in this study are not strictly comparable to this recommended cutoff as they are interval , not categorical data. Twenty three of the 38 life priority items (60.5%) were rated by participants as important to very important for having a good li fe. Of these 23 items, three important categories stand out (with some overlap). (1) Market related. Ten items are market related including agricultural crops (excess is sold), livestock (used as a store of value), and electronics. (2) Social life. Seven items are related to social life, including visits between family members and helping family. (3) Absolute necessities. Five items can be classified as absolute necessities such as clean water, food and taking care of children. The least important items in my analysis include a mix of local practices and reporting disliking due to their reputation for exploiting locals) and the culturally symbolic use of an charm for good luck in the hunt. Also of note is a reordering in importance of items between their ranks according to frequency of mention in free list exercises versus their final rank according to the CCA answer key ratings (Table 3 3). Cultural Consensus Analysis: Soc ial Support After my analysis of the 46 semistructured interviews I selected a list of ten common struggles and five important social resistance resources (Table 3 4 ). Respondents from both communities strongly share a common model of social support. Usin g the informal CCM I determined that the Eigen value ratio of the latent first to
127 second factors is 11.4:1. The first factor also accounts for 88.2 % of the variance between people. Average knowledge is high at 0.81 (Â± .08). Finally, the standard deviation statistic is below the cutoff for the formal CCM based on sample size, number of items and average knowledge (~.14). Two key sources of social support stood out in the analysis. (1) Family members. For each problem I tested family was the most important source of support with the exception of health problems, for which biomedical health professionals were rated as slightly more important than family. (2) Community leaders. Community leaders were highly valued for helping to resolve intra and intercommu nity problems. Family was most critical for dealing with lack of food, taking care of children, lack of transportation and sadness. Also of note, friends were an important source of emotional support to deal with sadness and community leaders were moderate ly valued to resolve i ntra and interfamily problems. Market Exposure and Cultural Models My first research question aims to test whether different levels of market exposure have led to distinct models of cultural consensus between AjÃ and Serrucho . I fin d that for both life priorities and social support market exposure has not resulted in distinct cultural models. My CCA results show that there is a single shared model of culture between AjÃ and Serrucho in each of the two tested domains. Comparing results of both analyses, however, demonstrates that the CCM of social support is more strongly shared and understood compared to the CCM of life priorities . Reliability statistics for the life priorities mod el are near the limits of a sufficiently shared model with an Eigen value ratio of 4:1 (cutoff 3:1) and a standard deviation of knowledge of .12 (cutoff .14). The final results also reveal that both life priorities and social support, while
128 shared between the communities under a first latent factor, systematically vary along the second largest latent factor with a preference for this residual agreement obtaining in Serrucho but not AjÃ . F igures 3 4 and 3 5 display the results of the CCA of life priorities a nd social support, respectively . The circles represent participants and are sized by age (bigger is older) and colored by community with residents of Aj Ã in red and residents of Serrucho in blue. The lower level of sharing in the CCA of life priorities com pared to social support is appare nt by the wider dispersal of participants along the first factor of knowledge in the X plane . The second factor of knowledge on the Y plane of each figure divides most residents by community. To understand the underlying na ture of this divergence below I compare average deviation from the CCA ratings/rankings keys (Figure 3 6 ), stratifying responses by community. Community Deviation The second research question intends to test whether market exposure leads to deviation in preferences for particular priority items and sources of social support. Residents in Serrucho consistently demonstrate a common knowledge of a second latent factor for both life priorities and social support. For life priorities , this second factor accounts for 18.2 % of variance on top of the 72.7 % of variance explained by the first factor in the model. To a lesser extent, the second factor for social support also a ccounts for additional variance (7.7 % beyond the 88.2 % accounted for by the first factor). Deviation in Life Priorities The systematic preference for the second latent factor of life priorities in Serrucho can be explored qualitatively by considering the 13 most divergent items (absolute difference between community ratings range is 0.53 2.28 on a scale of 1 5 ;
129 Figure 3 6 ). Twelve of the 13 are favored by residents of Serrucho and just one by residents in AjÃ . Only the symbolically important red pepper plant t j long used to ward off evil spirits rates as more important in AjÃ . Also of note among the 13 total items is having a zinc roof, an item tied to market integration. The remaining 11 locally significan t items are exclusively preferred in Serrucho . These are part of three overarching categories, (a) family and social life, (b) hunting and (c) health. (a ) There are four items related to family and social life: having a large family, gathering to do Tsim reside outside of ) Three items are tied to hunting: hunting with a bow and arrow (not a firearm), use of a symbolic charm to bring luck in the hunt, and practicing the seasonal fruit ritual ( , Bactris gasipaes or the peach palm is a sacred tree also used for making bows and arrow tips). (c ) Two items are related to health: use of a Q urpa ( more commonly known among Aymaran highlanders as a Mi llu ; Qurpa is a cognate of the Aymaran Qullpa , though this is actually the name for saltpeter, a different substance) to divine and treat supernatural illness and the use of forest medicine. Finally, having a family member who can weave s Ã¡ ray cotton carrying bags used to transport everything from crops to babies also rates more highly in Cosincho. Deviation in Social Support The social support items that deviate most between the two communities were determined using a natural cutoff indicated by a sc ree plot of the aggregate absolute differences between problem/support dyads as ranked by community members (absolute difference between rankings 0.48 1.48 on a scale of 1 5). The deviation of rankings in the domain of social support is primarily character ized by a division in the
130 perceived importance of community leaders to help resolve problems. Residents from AjÃ think community leaders and friends are more important for resolving issues as varied as transportation, community problems, sadness, spousal problems and family problems. By contrast, community leaders are only preferred for taking care of children in Serrucho (with most respondents mentioning teachers in school as the locus of this support). Discussion In longitudinal research among economica lly diverse residents of urban Brazil, Dressler and colleagues have found that lifestyle markers and social support are relatively stable over time. In this study I find that diversity in market exposure that has developed over the last quarter century doe s not result in distinct primary models of life priorities horticulturalists. The important caveat to this conclusion, however, is that market exposure does seem to be inversely related to a constellation of several traditionally and culturally significant status markers and sources of social support. That is, Serrucho with less market exposure has additional preferences for locally significant items and practices that are not shared by residents of the comparison co mmunity with more market exposure. In the context of well documented increases in market related consumption and exchange patterns that track along a gradient of market exposure, my results add credence to the idea that cultural change is occurring among t . The nature of the deviation in life priorities is so dramatic that only one of the 13 most divergent items is preferred in AjÃ . The t j red pepper bush is a locally important item but it is singular in its cultural s recognizes the bright red fruit of this plant as a protection against forest spirits and evil
131 that might otherwise freely enter the home a nd threaten the health and well being of its residents, in particular smal l children (Huanca 2008) . Therefore, its preference in AjÃ may be linked to a desire of residents there to protect themselves from danger, which fits with the results of survey research in this community that has identified worse self perceptions of securi ty and health ( Chapter 5 ). The other outlier is a zinc roof, which is preferred in Serrucho where production of locally harvested and woven palm roofing panels ( jatata in Spanish) is a critical source of income for the community sec ond only to logging. Among those in AjÃ , palm panels are even more commoditized since it is the ir river port that merchants use for collection and storage of palm panels they purchase from communities up river. In this way, despite a professed preference for the breathability of palm panels, zinc panels have come to be preferred for their durability and prestige over the commoditized palm panels . The unimportance of community leaders in Serrucho may also reflect a preference for locally specific social fo and mobile group known for their frequent movement back and forth between settlement s but also for deference to the priorities of kin networks (Daillant 2003 ; Ellis 1996 ). Only since the founding of community based bilingual schools 30 years ago and GCT , has it become more common for people to acknowledge community authority and leaders apart from shaman ( who have not existed since the 1980s ; Ellis 1996). T his history of social patterning makes it likely that community leadership would be valued less by th ose who otherwise prefer the long established pattern of autarky .
132 Analyses of the data allow me to draw a few important conclusions about the rela tionship between market exposure and culture change in this non industrialized small scale society. 1. There is a moderate level of sharing in the domain of life priorities between AjÃ and Serrucho that demonstrates common cultural preferences but also sugges ts a state of flux when compared to the higher level of sharing found in the domain of social support. 2. The systematic striation between AjÃ and Serrucho along the second largest latent factors of both cultural models suggests that community level differenc es in the meaning of the domains are leading to deviation in preferences within cultural domains. 3. Qualitative analysis of community level preferences for the most divergent domain items demonstrates a unique preference in Serrucho for established Tsimane cultural markers and support mechanisms. Cultural consensus analysis relies on the assumption that there is only one model for any given domain and its reliability tests hinge on this assumption. In a rapidly changing context, however, we would expect t he strength of sharing to decrease as a function of increasing variance among respondents in their knowledge of the importance of domain items. The data I have presented here fit this expected pattern along a previously established proxy for market exposu re. Furthermore, my qualitative analysis of this deviation in knowledge for particular domain items suggests that it has ethnographic validity . More market exposure results in less knowledge of, and value for, culture in AjÃ . At the same time, this same community also prefers social support from a n asymm etric community power structure that is a The analyses I present regarding deviation from shared models of life prioritie s assumption of CCA. It is conceivable that, especially in the context of rapid change,
133 CCA could be adapted to accommodate additional ethnographically valid latent construct s that emerge organically from the data. Limitations Rigorous hypothesis testing of change requires a longitudinal design such as a cohort or panel study. In lieu of such a design, cross sectional results must be interpreted with caution as they may refle ct unanticipated confounds and could confuse cause and effect. Additionally, although the sample sizes I use for the iterative structured methods meet agreed upon standards, they are limited in geographic and population scope having been collected in jus t two communities.
134 Figure 3 1 . Location of the two ethnographic study communities and nearest major market towns.
135 Figure 3 2 . The photo of a ladder and corresponding scale used to explain ratings exercise options for evaluation of items in the domain of lif e priorities. The text reads, 1 .
136 Figure 3 3 . Alan Schultz. 2012. Examples of the photo cards used to identify sources of social support in the rankings exercise: A) Family, C) Friends, intentionally omitted), D) Community leaders, E) Medical doctors and F) Outside leaders.
137 Figure 3 4 . Scatterplot of loadings for the model of life priorities colored by AjÃ ( accessible community in re d) and Serrucho (remot e community in blue; markers sized by age; bars are 95% confidence intervals) .
138 Figure 3 5 . Scatterplot of loadings for the model of social support colored by AjÃ ( accessible community in re d) and Serrucho (remote community in blue; markers sized by age; bars are 95% confidence intervals) .
139 Figure 3 6 . D eviation in community average item ratings |0.53 | to | 2.28| for the domain of life priorities (x axis: accessible community , AjÃ ; y axis: remote community , Serrucho
140 Table 3 1. Purposive life stage sampling a . 15 34 years 35 49 years years Female Less w ealthy Semistructured i nterviews ( n =46 ) 0.41 0.28 0.30 0.52 0.50 Free list e xercises ( n =45) 0.44 0.29 0.27 0.47 0.51 Ratings/Rankings e xercises ( n =69) 0.45 0.29 0.26 0.48 0.51 a Proportion s . Table 3 2 . Free list of life priorities . Item a Rank Frequency Crops 1 255 Market tools/materials 2 207 Purchased food 3 128 Livestock 4 98 Forest meat and fish 5 70 Local tools ( s Ã¡ray bags ) 6 67 Modern medicine 7 60 Visits between family 8 58 Shopping trips 9 53 Hunt with firearm 10 51 Drink sh ocdye ( homebrew ) 11 48 Education 12 45 Family helps each other 13 33 Non family helps 14 30 Care for children 15 28 Reside in birth community 16 27 Good food 17 26 Clean water 18 24 Electronics 18 24 Forest medicine 18 24 Good clothes 2 1 23 Good house 2 1 23 Dogs 23 22 Family 23 22 Plant ( red pepper ) bushes 23 22 Listen to Radio Horeb news 26 18 a Some free list responses were combined based on e thnographic data and the evaluation of native
141 Table 3 3. Cultural consensus key of life priorities. Item Consensus r ating a Consensus key r ank Free list r ank b Care for children 4.95 1 15 Clean water 4.94 2 18 Forest meat and fish 4.93 3 5 Crops 4.9 0 4 1 Family 4.9 0 4 23 Good food 4.89 6 17 Market tools/materials 4.88 7 2 Livestock 4.86 8 4 Visits between family 4.85 9 8 Education 4.84 10 12 Good house 4.84 10 21 Listen to Radio Horeb news 4.81 12 26 Purchased food 4.8 0 13 3 Shopping trips 4.8 0 13 9 Good clothes 4.71 15 21 Modern medicine 4.71 15 7 Hunt with firearm 4.65 17 10 Weave s Ã¡ ray (cotton bags ) 4.59 18 6 Electronics 4.59 18 18 Reside in birth community 4.59 18 16 Listen to flute music 4.45 21 131 Drink (h omebrew ) 4.33 22 11 Family helps each other 4.04 23 13 Q urpa for supernatural healing 3.92 24 . Forest medicine 3.76 25 18 Plant ( red pepper ) bushes 3.63 26 23 Dogs 3.45 27 23 Non family helps 3.36 28 14 Zinc roof 3.36 28 101 Practice the fruit tree ritual 3.03 30 58 dance 2.97 31 131 Hunt game with just a bow 2.82 32 131 S mall family 2.8 0 33 101 G as stove 2.51 34 131 Traveling merchants 2.3 0 35 82 Use ( charms ) for luck in the hunt 2.15 36 . Smoke home grown ( tobacco ) 1.86 37 59 Non Tsimane' friends 1.8 0 38 131 a Item ratings are calculated in CCA by weighting the raw average score given to items b Free list rank is based on the raw frequency of items in the combined data set of free list responses; items wi th the same frequency are assigned the same rank.
142 Table 3 4. Rank of problems and sources of social support . Problems Sources of social s upport 1. Family and personal health 1. Family 2. Taking care of children 2. Friends 3. Crops and food 3. Local officials 4. Lack of money 4. Health workers 5. Sadness 5. Outside people and organizations 6. Spousal problems 7. Interfamily problems in community 8. Lack of work 9. Intra and Intercommunity problems 10. Transportation
143 CHAPTER 4 EVALUATING THE ASSOCIATION BETWEEN BLOOD PRESSURE AND A CULTURALLY MEANINGFUL STATUS GRADIENT AMONG FORAGER HORTICULTURALISTS Overview A large proportion of variance in length and quality of life in high and low income countries is attributable to causes apart from absolute material deprivation . This var iation is linked instead to chronic diseases ( WHO 2011 ). Across all industrial societies about two thirds of the variance in health outcomes is due to chronic disease rather than absolute deprivation (Adjaye Gbewonyo and Kawachi 2010; Lim et al. 2012; Wilkinson a nd Pickett 2007) . The difference between absolute and relative deprivation h as been theorized as being a matter of capabilities or what individuals can do considering their opportunity and ability (Sen 1985 ). It has also been described as differences i n social functioning and human needs (Marmot 2005). Others adapt Robert 2000 ). Ultimately, among population health meaning of being poor, unemployed, socially excluded, or otherwise stigmatized also as a pathway of psychosocial stress (Runciman 1966; Wilkinson and Marmot 2004:9). I n the industrialized world , determining the meaning of relative status is complicated by its lo ng history of being tied to consumption (Sweet 2010; Veblen 1918) . For example, functional magnetic resonance imaging (MRI) studies comparing consumer brands have shown that when experiments are blinded, people cannot differentiate between high status and common versions of the same products (Fehr and Rangel 2011). However, when people are told a product is considered the best of its
144 kind, their physiological enjoyment of it is measurably enhanced compared to those informed that the same product is of avera ge or worse quality (McClure et al. 2004; Plassman et al. 2008). This disjunction between materially equivalent quality and meaningful experience for market status items is one of many examples why relative status requires a complex and culturally salient measure ment that goes beyond SES. Medical anthropologists distinguish status and SES by building explicit measure ment s of culturally meaningful status indicators. Cultural consonance an n model has been studied in several salient domains (e.g. lifestyle, social support, diet, family life and national identity) and in many varied settings (Dressler and Bindon 2000; Dressler et al. 2009; Chick et al. 2014; Snodgrass et al. 2011; Sweet 2010) . When confounders and interactions with other indicators of status are controlled , consonance has shown a consistent positive association with better health outcomes (Dressler 2012) . In particular, the association s between cultural consonance in lifestyle and health have been shown to interact with SES, altering association s with health in industrial societies through an incongruity between culturally salient status and SES (Dressler et al. 1997; Dressler et al. 1998; Dressler 2004 ). Despite the variety of studies that have investigated cultural consonance, there are very few examples in non industrial societies. R e yes GarcÃa and colleagues measured consonance in lifestyle among forager horticulturalists by creating post hoc measure ment s from existing l ongitudinal data (2009; 2010). They found that consonance in lifestyle was significantly positively correlated with better psychological but not physical health. However, due to the post hoc formulation of their measure ment
145 it is not clear whether the item s measured were best suited to the cultural domain or simply those that were available. In this study, I contribute new research from a non industrial society to add to our understanding of relative status and health. I investigate a forager horticultural ist group, questions about the meaningful significance to health of being relatively deprived in a setting where occupation, education and wealth matter little for rated that relative social status based on SES indicators does not matter for adult health as it does in the so cial gradients of industrial societies (Undurraga et al. 2010). Part of the explanation for this unique unimportance of standard SES indicators is that types of occupation and levels of social capital are extremely consistent throughout the population , mostly eliminating the common confounds to relative status of self control and social support (Lynch and Kaplan 2000) . The social gradien t in health, however, is not absent but has been linked to a gendered (all male) measure ment of local ascribed social rank (Reyes GarcÃa et al. 2008). I improve on this work by using a novel measurement of oes not suffer from an explicit gender bias. opportunity to gain insight into mechanisms that help to determine the meaning of relative status when influence from SES i ndicators is lar gely attenuated. Specifically, I aim to investigate whether : 1. individual consonance in shared life priorities is inversely associated with blood pressure among a sample of indigenous forager horticulturalists . 2. socioeconomic status change s the nature of asso ciation s that might exist between blood pressure and consonance in this sample .
146 Methods Research Setting and Sampling I conducted mixed methods research in several the Jos Ã© BalliviÃ¡n province , Beni department, Bolivia from 2011 until 2013. This included two years of participant observation as well as semistructured interviews, free listing exercises, ratings/rankings exercises and an eight community epidemiologic survey. Jos Ã© BalliviÃ¡n province is located in the southern Am azon Basin, a mixture of tropical and subtropical moist broadleaf forests, and home to 80,121 permanent residents of which 42 % (33,868) are indigenous and 15.5 % ( INE 2014 ) . In total, INE 2014 ). Jo sÃ© BalliviÃ¡n has been undergoing rapid population growth and dramatic shifts in how people self identify themselves. In just eleven years (2001 2012), the recorded population of the province grew by 20 % (from 66,304) while the recorded indigenou s population grew by 307 % % (from 3,614 ; INE 2014 ). These data undoubtedly represent substantial real growth, however, among indigenous groups at least part of the increase is an artifact of improved census me asurement and increasing acknowledgement of indigenous identity . This has happened in two ways , (1) through a growing awareness of the importance of census data for determining local nd, (2) through an effort by the national census to improve its enumeration of citizens living in geographically isolated communities (where most lowland indigenous groups reside). Beni department is the second largest of the nine national departments by land mass and the second smallest by population, with a density of just 5.1 persons per square mile compared to 2 4 per square mile in all of Bolivia ( INE 2014 ). Low density
147 and the local climate have shaped the major industries of the department includin g cattle ranching, logging and farming. Over the last several decades economic growth has come mostly from logging and the cattle industry. Transportation has long been unpredictable and there has never been a paved highway that fully traverses the departm ent though one is currently under active construction including in Jos Ã© BalliviÃ¡n . The lack of development in Beni is also reflected in average yearly household incomes (principal occupation only) estimated at BOB$ 22,908 (about USD $3,320) with 4.5 persons per household ( INE 2014 tudy average a slightly higher BOB$ 37,464 (USD$5,430) yearly household income (imputed) inclusive of all wage labor, sale of crops and crafts, social security programs, and remittances (exclus ive of consumed crop value) among a slightly larger average household size of 6.0 persons. The average incomes of households in this study are similar to those found in crop consumption is included ( BOB $5 0,772 /year in this study ; Undurraga et al. 2010 ). The average level of education of participants is 3.3 years, which is also comparable to the average for the province (3.1 years ; INE 2014 househol ds , however, is their relative geographic isolation in communities mostly clustered along the Maniqui river and its tributaries. Average round trip travel time to reach a market town from the eight communities studied is 11.8 hours ( range= 1 36 hours) provi ded canoe and vehicle transportation is readily available. Several previous longitudinal and cross sectional studies have demonstrated that the geographic isolation has created a gradient of market exposure with distance to market from
148 communities along th e Maniqui acting as a good proxy for market exposure (Godoy 2001; Byron 2003; Gurven and Winking 2008) . Participant Observation and Ratings E xercises rally salient life priorities I first built and tested a cultural model of the domain . I began by carrying out a formative 2013 to better explore aspects of local life priorities (see Chapter 2 ). The f irst ethnographic community is moderately accessible requiring from one to two hours of travel round trip by vehicle to visit the nearest market town and hospital ( F igure s 2 2 and 4 1 ). The second community is much more remote requiring from 24 to 36 hour s of travel by motorized canoe round trip to visit a market town . I purposively chose the ethnographic communiti es to capture variation in life priorities due to differential exposure to market influences. In each communi ty I used long term participant obs ervation and semistructured As part of this process I collected daily systematic field notes and expanded on these nightly to improve rec all and comprehension of the data ( see C hapter 2; Bernard 2011 ). My participant observation data shaped subsequent structured interviews to assess life priorities. In total, I conducted 46, 45 and 69 semistructured , free list and ratings/rankings intervi ews, respectively ( Table 3 1 ). The cultural modeling process is described in detail elsewhere ( see Chapter 3 ). Briefly, I based the ratings exercise for life priorities on free lists obtained from purposive life stage samples selected for variation in age group, approximate wealth and gender in the two ethnographic
149 people you need to live a good life here in the community This question varies from past research among t to model lifestyle (Reyes Garc Ãa et al. 2010). This distinction is important in context and instead use the term , which has a translation somewhere between relative and brethren. The word , culture as viewed by outsiders (called Napos I asked respondents to provide an exhaustive list in response to my elicitation question and recorded all responses given. I also made use of follow up prompts when respondents did not list more than 20 items on their own. My prompt translates as, list responses into standardized items based on knowledge gained during ethnography and then confirmed the logic of my results with bilingual My final ratings exercise h ad 38 items in total ( T able 3 2). Twenty six items were chosen because they were frequently mentioned in free lists (68% ). A natural cut off in the aggregate free list data was used to determine the exact number of popular items selected. I also include d an additional 12 lower frequency items (32% ) based on observed cultural and community specific salience and two items that did not get mentioned in free lists . The inclusion of lower frequency items was necessary to increase variation in responses and m easurement accuracy of the cultural consensus model (CCM; Weller 2007 ). I next conducted 33 and 34 ratings/rankings exercises with fresh samples in the Aj Ã and Serrucho , respectively. I selected r espondents using the same purposive life -
150 stage sampling des ign as the free lists ( T able 3 1) and I based sample sizes on numbers found sufficient to exhaust important themes in previous research (Weller and Romney 1988; Handwerker and Wozniak 1997). Each ratings exercise lasted approximately 30 minutes and my enti re ratings/rankings interview usually required 45 60 minutes to complete. Due to low literacy rates, I gave respondents the option to evaluate each of the 38 items by indicating their rating on a five rung drawing of a ladder or with corresponding verbal c ategories ( Figure 3 2 ). The five categories consensus analysis on the ratings data using AnthroPac and UCINET software by Analytic Technologies (Borgatti et al. 2002). Cultural consensus analysis is an inverted factor analysis used to test levels of agreement between participants who are weighted according to their demonst rated expertise in the overall domain (Romney et al. 1986). As the formal consensus model requires dichotomous or multiple choice response data I opted for the informal model to accommodate my interval data. Consonance in L ife P riorities From May to June 2 013 I conducted an epidemiologic survey with adults aged 15 75 years from eight different villages in and near the Maniqui river region ( Figure 4 1 ). Community cluster sample s were co llected in six geographically distinct settings and eight unique communities. Cluster sample size was roughly based on total population of each community, with samples from smaller communities about half the size of larger communities (not listed). The sample was collected from four sm all communities (50 150 persons) and four large communities (200 400 persons).
151 I conducted the electronically using handheld devices that helped to reduce the potential for random and systematic errors during manual database entry and cleaning. The measurements for this study include d blood pressure, anthropometry, a 38 item cultural consonance module and important covariates. I selected survey communities to maximize variation in their po pulati on size, access to trade, available work, exposure to non universal willingness to participate I conducted a lottery in each community to randomize the selection process. All local resi dents within the eight communities who would be present d uring the survey period (two to five days per village) and at least 15 years of age were eligible to take part . I calculated t he measurement of consonanc e from self reports of material goods and beha viors on a scale from 1 5 for the preceding month (when applicable). Consonance module questions corresponded to the cultural consensus items ( Table 3 3 I asked respondent s to report how often they had a sufficien t quantity of clean water during the last month. R esponse options translate as 1 Never, 2 Very little, 3 Sometimes, 4 Often and 5 Always. I calculated consonance scores report of ownership or behavio r and the consensus key score for each item summed across all 38 items and then subtracted from the maximum possible sum of absolute differences ( i.e. 156.35) compared to the consensus key. Blood Pressure and C ovariates Blood pressure was the primary study outcome. I took three measure ment s after respondents had been seated for at least 10 minutes and dropped the first
152 measurement to attenuate the potential for researcher induced hypertension. I report the average of the second and third measurement s. I as sessed blood pressure with a validated and automatic monitor to further limit measurement bias (Omron Model HEM 705CP; Omron Healthcare Inc., Vernon Hills, IL; Artigao et al. 2000; Vera Cala et al. 2011). I calculated c ovariate dat a for body mass index (B MI) from height (cm) and weight (kg) measurement s taken with a portable standiometer and scale. I obtained monthly household income just once for each household using a standardized income questionnaire covering all sale of crops/crafts/animals, loans take n, payments received, wages or contracts paid, rents received and any other reported income. I limited the period of recall to the past month to reduce recall bias. I estimated household wealth using a standardized wealth questionnaire covering most commo n forms of material value items enumerated consisting of plastic water jugs, utensils and bullets and the highest value items including canoes and motors, livestock, shotguns, motorcycles and chainsaws. V alues were estimated at the current local market price to replace an item. Cash assets were minimal and I excluded them from wealth estimates to prevent conflict within the SES variable calculation that combines per person income (PPI) and per person wealt h (PPW). No participant reported a formal credit union or bank account. To estimate members, regardless of age. Due to low education and occupation variation I tested multiple in dicators as potential SES variables including years of education, monthly household income,
153 household wealth, PPI, PPW and loadings of principal components using combinations of these variables. Formal education levels (3.3 years Â± 2.9) were dropped due to redundant measurement in the CCLP module. Instead, I used the first factor loading from a principal components analysis of PPI and PPW as SES because it accounts for 77 % of the shared variance between the two variables. This composite measurement helps to prevent multicollinearity due to overlap of income and wealth when entered as independent variables . It also accounts for more variance than income, wealth, PPI or PPW when used singularly. My decision to use PPI and PPW as my SES measures also helps to a ccount for different resource demands due to household size, the inconsistent nature of month to month income locally and an established high degree of Table 4 1; Undurraga et al. 2010). Statistical Anal ysis I used multivariable linear regression analyses to examine systolic and diastolic blood pressure separately in models with SES, CCLP and interaction terms combining SES and CCLP ( Table 4 2 and Table 4 3). I controlled final models for covariates of ag e, sex, BMI and SES . Due to a relatively high pregnancy rate among the sample (7%), I included pregnancy to account for gestational hypertension unrelated to the independent variables under investigation (Wallis et al. 2008). I present results using the in verse of blood pressure to correct for a skewed distribution and meet the assumptions of regression . Also, to ease interpretation of effect sizes I present standardized coefficients (Beta coefficients refer to how many standard deviations the dependent va riable will change, per standard deviation increase in the predictor variable. ). Finally, I examined variance inflation factors, condition number and tolerance fo r evidence of multicollinearity. I also inspected ,
154 studen tized residuals, hat matrix values) for evidence of influential observations. I did not use sampling weights as I did not aim to measure population parameters. Results C ultural Model of Life Priorities My results confirmed moderate sharing in the domain of life priorities including an Eigen value ratio of 4:1 with the first factor (representing the latent domain) accounting for 72.7 % of variance (Figure 3 4; Weller and Romney 1988) . Average knowledge also indicated sharing with a mean of 0.63 (Â± .12). The f inal rank of items based on consensus key scores highlights the valu e of the insights I gained in the ethnographic phase of research ( Table 3 3 ). Several items I included in the ratings exercise based on observed but little reported importance were highly rated, including listening to local news, listening to flute music, and use of a Qurpa alum/ double sulfate sal t purchased from Aymara n highlanders ( known among Aymara as a Millu ; Qurpa Qullpa , though this is actually sickness diagnosis and spiritual and bodily heali ng ( see also Ellis 1996:185). There was little correlation between frequency rank from the free lists and the consensus key. For example, care for children and clean water were the 15 th and 18 th most frequent items, respectively, in the free list data but ranked first and second on the consensus key ( Table 3 3 ). Conversely, some of the most frequently mentioned items in the free lists
155 Co nsonance and Health O utcomes S ample characteristics stratified by low and high SES are listed in Table 4 1. Those who high represent 25.8% of the total sample ( n = 54 ). These respondents tended to have lower blood pressure (2mm Hg SBP and 1mm Hg DBP on average), be more consonant in life priorities (0.62 SD more), have 0.4 years more of education, be wealthier (PPW BOB$6,307 greater) and live farther away from market towns (6.6 hours farther). I looked at the distribution of SES in the sample ( Fig ure 4 2 ). Most individuals are clustered just below the mean for SES. I also found regression diagnostics to be satisfactory. Variance inflation factors ( maximum = 1.48 ) and condition number ( 2.80 ) indicate that multicollinearity is not likely to be a significant problem. respondents with values greater than one. I explored the raw data using bivariate non parametric l ocally weighted scatterplot smoothing (Lowess) curve regression for the CC LP variable. Figure 4 my multivariable linear regression models (described below) this bivariate relationships holds. Cultural consonance in life priorities has a significant inver se association with SBP. I include step wise multivariable linear regression models with standardized Tables 4 2 and 4 3. Figure 4 4 shows an adjusted linear comparison of blood pressures for men versus women from the fi nal model . Men in the sample average SBP that is about 15mm Hg higher tha n women. Overall, I find evidence that results for the SBP and DBP regression models help answer my study questions. Models B address the first study question (1) by demonstrating inv erse associations between CCLP and blood pressure. I also find that in the full models SES
156 has a significant inverse relationship with SBP and DBP. Models C also help to answer my second study question (2) by showing that SES acts as a moderator variable f or the association between blood pressure and consonance . To understand the variation in context, Figure 4 5 presents average consonance scores of residents from the two ethnographic study communities for each life priorities domain item. In the basic mod els age and BMI are significantly positively associated with blood pressure while gender and pregnancy are significantly inversely associated with blood pressure. This fits with most population research on gender differences in blood pressure between men a nd women. Of note, Gurven et al. recently found that in the women have higher average levels (2012). My data does not support this conclusion. In Models B SES is not signifi cantly associated with SBP but CCLP is significantly inversely associated with SBP. The significance and effect size of the CCLP coefficient for SBP increases with each better specified model but only the CCLP*SES interaction is significantly associated w ith DBP. Overall, there is a significant inverse association between blood pressure and the interaction of cultural consonance and SES (Figures 4 6 and 4 7; Models present inverse blood pressure measurements) . Participants in this sample with high SES tend to have higher blood pressure unless they also have high CCLP. This means that those with higher SES suffer more from the consequences of low CCLP. For example, according to the models someone with a 1 SD CCLP and 1 SD SES would have a ( 0.22 + 0.16 + 0.20 = 0.14 SD) 2.14mm Hg higher SBP. However, someone with a 1 SD CCLP and +1 SD SES would have a (0.22 + 0.16 + ( )0.20 = 0.18 SD) 2.75mm Hg higher SBP. I graph interaction
157 effects by low and high SES for SBP and DBP in Figures 4 6 and 4 7 using predic tive margins plots. Discussion Question One: Is individual consonance in shared life priorities inversely associated with blood pressure among a sample of indigenous forager horticulturalists? I find that individual approximation of culturally salient life priorities is inversely horticulturalists diverse in age, income and market proximity. As CCLP levels increase in the sample, blood pressure tends to decrease in a culturally meaningful sta tus gr adient. This cultural status gradient is detectable despite only moderate overall variation in blood pressure measurement s compared to the level of variation found in most industrial societies. has also found sim ilarly small levels of variation in blood pressures (Gurven et al. 2012). Also of note, there is no corresponding independent SES gradient in blood pressure. It only exists when the model contains the interaction variable. This aligns with recent longitudi nal p anel research among a large ies with varied market exposure that found intra community wealth rank and inter community wealth inequality do not seem to matter much fo r self reported health (Undurraga et al. 2010) . By contrast, loca l l y ascribed social rank for men has been positively associated with various measurement s of adult nutritional status (Reyes Garc Ã a et al. 2008) . The associations between DBP and CCLP had smaller effect sizes and model R 2 estimates than SBP. This result matches other research on consonance and blood pressure that has found strong associations with SBP but mixed or attenuated results with DBP (Dressler 2000; Sweet 2008). One potential explanation of these outcomes is
158 that the physiologic mecha nisms underlying the stress response make blood pressure a helpful but ultimately imprecise measurement for detection of acute and chronic psychosocial stress (Ice and James 2007). S ystolic blood pressure is largely due to contractility of the ventricles and the amount of sys temic resistance to blood flow while d iastolic pressure reflects peripheral vascular resistance (Matthews et al. 1993). The connection between contractility of ventricles, overall reactivity and stress is part of the physiological mech anisms that link chronic psychosocial stress to cardiovascular health, though these connections are quite complex (Lovallo 2005:74; Schneiderman et al. 2005). By contrast DBP is known to be less predictive of this health risk (Carroll et al. 2001; Hildrum et al. 2008). Since blood pressure is an imprecise measurement of chronic stress its overall predictive power is also likely attenuated in studies of forager horticulturalists due to the small amount of variation present in such populations and low average blood pressure s that frequently fall below clinical levels of significance (Dressler and Bindon 1997). as documented by previous researchers, any one individual in this study is n ot likely to Gurven et al. 2009; Nyberg 20 09; Reyes GarcÃa et al. 2010). The low average blood pressures I found (116/68mm Hg) are typical for societies of foragers, pasto ralists and horticulturalists who have been found to average approximately 115/75mm Hg (Dressler and Bindon 1997; Fleming Moran and Coimbra Jr. 1990; Steffen et al. 2006; Waldron et al. 1982). Gurven and colleagues recently reported a 2.9% prevalence of pe rsistent
159 (2012). I found similar, if slightly higher, blood pressures in this study with a 5.7% point prevalence of hypertension (140/90mm Hg), 29.7% point prevalence of pre hypertension (120/80mm Hg) and no respondents on antihypertensive medication. By comparison, the prevalence of hypertension (exclusive of prehypertension) in all of the Americas is estimated at 35% (WHO 2010). A large body of research has revealed the exis tence of a social gradient in health even when income, education and occupation are controlled for or eliminated (Marmot et al. 1978 b ; Sapolsky and Share 2004). What is less common is being able to link those gradients to specific culturally salient items that make up meaningful latent domains. Question Two: Does socioeconomic status ch ange the nature of associations that might exist between blood pressure and consonance in this sample? Socioeconomic status modifies the association between CCLP and blood pressure in this study. The nature of these interactions means that those with higher SES are the most sensitive to CCLP levels resulting in a SES moderate d gradient in blood pressure. This result partially resonates with previous research on lifestyle incongruity that has found deleterious health consequences for people undergoing rapid culture change and market integration (Dressler and Bindon 1997; Sorens en et al. 2009; Liebert et al. 2013; McDade 2002; McDade and Nyberg 2010). However, the nature of the interaction only affecting those with high SES is unique. The result seems to suggest that people striving to maintain a high SES in the context of a sma ll scale non industrial society are actually those that most need the psychosocial buffer provided by being cultural ly consonant. If true, this implies that those who have low SES and are little affected by CCLP may actually not need an y additional buffer against
160 psychosocial stress to maintain their health . This brings up the question: if cultural consonance is not responsible for their extraordinary cardiovascular health, what is? A possible explanation for this result is that the meaning of having lower SES in a rapidly changing context of increased market integration has become almost as important as the experience of being culturally consonant in life priorities. A review of my ethnographic data is helpful for understanding these results in context. A propos to the research questions here, several residents from the two ethnographic communities expressed strong opinions about what it means to live a good life now. A phrase he more market and customs from the recent past. Despite this common explanation, though, the rea lity is not so clear. As demonstrated in my analysis of the shared cultural model of local life priorities (Chapter 2) there is actually significant diversity in this domain. So, while people rarely expressed to me a desire to emulate the lives of their gr andparents, in ratings and in reported practice their beliefs and behaviors were often fairly well aligned with those of elderly kin (see Figure 4 5) . In particular, forest meat and fish commonly just called (good food) are still highly sought after, as are the accouterments that allow for their successful Finally, family, crops and social support that have long been high priorities, still remain important (Reyes GarcÃa and TAPS 2012 ). Consonance in the doma in of life priorities associates most strongly with systolic blood pressure in this study. The role of SES as a moderating variable, further suggests
161 that only those who manage to simultaneously achieve high SES while successfully approximating life priori ties compared to their neighbors, reap substantial benefits in their cardiovascular health. It would therefore not be sample to only approximate local models and ignore SES if they want the full hea lth benefits of high statu s. The mechanism for this likely has to do with increased psychosocial stress and related disease due to the anxiety of status incongruity . My results feed into a larger stream of literature on culture change and health. For example, Steffen and colleagu analysis of acculturation, which concluded that the stress of ongoing culture change is itself a major component of increased blood pressure in our ever changing industrialized societies (2006). A measurement like cultural consonance being locally and temporally relevant to the meaning of social status can therefore provide novel insight into the meaning of material and behavioral components of status that help to buffer individuals from change induced stresso rs. In this study the results suggest that adherence to life priorities is actually most important for those striving to integrate into the market by maintaining a high SES, the exact individuals one might expect to be the first to reject the prevailing co nsensus of a mostly non market integrated group. In the context of rapid market integration and population growth occurring among that acts as a buffer against the psy chosocial stress of culture change, but only for those who can keep up. The effectiveness of this buffer, however, is moderated by this sample and in past research among I conclude that my data more
162 likely suggests a shift in the meaningful categories people use to assess the status of those around them, rather than a change in absolute material status . Finally, relative deprivation in culturally meaningful s tatus among this sample is also colored by the rapid population growth and increases in income and overall health documented over the last decade ( Godoy et al. 2009; INE 2014). Particularly striking are some of the political economic changes that have occu rred (see Chapter 1 and 2) 2009 the first indigenous president of Bolivia and with his endorsement. An villages near power lines and potable drinking water. They have also just registered their true size at the federal level by being fairly en umerated in the 2012 national and the push and pull factors that can alter belief, behavior and health. Limitations My SES variable does not contain education or occupatio n. The decision to exclude these variables is explained above. The consequence of doing so means that the SES variable is not strictly comparable to other versions of SES used in other studies from industrial societies. Next, the final models (C) for SBP a nd DBP only explain 4 and 2.7% more variance, respectively, in the sample than the basic models (A). The true population level correlation could be larger or smaller than this estimate. Since I used a version of cluster sampling that limits the sample to purposively chosen communities, it is possible that the data obtained contain an undetected endogenous
163 bias. However, adjusting for potential community clusters does not change the nature of the associations, it only attenuates them some. Next, modest lev els of additional variance in blood pressure explained by the final models might be due to low average blood pressure among this sample. Those induced hypertension. Longitudinal resea rch has shown that individuals with hypertension are more reactive to psychosocial stressors than those with lower average blood pressure (Flaa et al. 2008). It might also be the case that the small additional variance explained is actually larger than ind icated due to misspecification of the more basic models partly due to omitted variable bias. Ultimately, additional physiological biomarkers of provide more robust links to he alth. Finally, the cross sectional nature of this study does not allow for a determination of directionality in associations or a contribution to causal research. It is unclear, for example, if the association between CCLP and blood pressure occurs because having low blood pressure and potentially low stress leads participants to acquire items and to the cultural model of life priorities leads to less psychosocial stres s and subsequently better blood pressure.
164 Figure 4 1. Location of the eight ep idemiologic survey communities (including the two ethnographic c ommunities ) and nearest major market towns.
165 Figure 4 2 . Histogram of socioeconomic status distribution i n the study sample .
166 Figure 4 3 . Locally weighted scatterplot smoothing (Lowess) curve regression of the bivariate relationship between systolic blood pressure and cultural consonance in life priorities (two outliers not pictured) .
167 Figure 4 4 . Association between age and systolic blood pressure (1 SD=15.25mm Hg; p<0.05; bars represent 95% CI) stratified by gender and adjusted for pregnancy status and body mass (note: y axis values of blood pressure are plotted from low to high, they are not inverted as in the model).
168 Figure 4 5 . Average community consonance in life priorities for each item tested , limited to and stratified by the accessible ( AjÃ ) and remote (Serrucho) communities [*scores based on respondent recall of previous month exce pt where indicated; consonance is calculated as = (absolute deviation from cultural consensus key scores maximum possible absolute deviation from key ) /1 ]. 0 1 2 3 4 5 Used an isÃ¤tri hunting charm Danced to Tsimane' music Had help from non-family Hunted with a bow and arrows Smoked homegrown tobacco Listened to flute music Had help from family nearby Have non-Tsimane' friends* Exchanged with traveling merchants Used a gas stove Know about forest medicine* Hunted with a rifle/shotgun Had enough livestock Had enough shocdye' homebrew Ate enough bush meat and fish Had enough clean water Lived in the community a long time* Had enough good food Had enough good clothes Visted family Have a big family* Do the VÃ¤ij (peach palm) ritual* Amount learned from school* Had enough purchased food Had enough crops Use a qurpa to diagnose and treat* Took good care of children Had good dogs Made shopping trips Had enough market tools and materials Had enough electronics Had a zinc roof* Had a nice house Take biomedicine when needed* Got along with your family Used handmade cotton bags Listened to Radio Horeb Remote (n=34) Accessible (n=37)
169 Figure 4 6 . Interaction between socioeconomic status ( SES ) and cultural consonance in life priorities associated with systolic blood pressure (1 SD=15.25mm Hg; p<0.05; bars represent 95% CI) adjusted for age, sex, pregnancy status and body mass (note: y axis values of blood pressure are plotted from low to high, they are not inverted as in the regression model) .
170 Figure 4 7 . Interaction between socioeconomic status ( SES ) and cultural consonance in life priorities associated with diastolic blood pressure (1 SD=9.32mm Hg; p<0.05; bars represent 95% CI) adjusted for age, sex, pregnancy sta tus and body mass (note: y axis values of blood pressure are plotted from low to high, they are not inverted as in the regression model) .
171 Table 4 1. D escriptive statistics of study sample . High SES ( n =54) Low SES ( n =155) Total ( N =209) Systolic blood pressure 114.8 (13.9) 116.8 (15.5) 115.7 (15.25) Diastolic blood pressure 66.6 (9.4) 67.5 (9.0) 67. 3 (9.08) Age, y 34.7 (15.3) 34.2 (13.8) 34.3 (14.17) Sex, % female 51.9 52.9 52.6 Body mass index 24.0 (2.9) 24.0 (2.9) 23.9 (2.87) Education, y 3.6 (2.8) 3.2 (3.0) 3. 3 (2.93) Pregnant, % 11.1 5.2 7.0 Cultural consonance in life priorities a 91.7 (11.8) 85.5 (8.8) 87.1 (10.02) Household size 5.0 (2.7) 6.4 (2.5) 6.0 (2.63) Monthly per person income and crops consumed, BOB 1,929 (1,665) 416 (206) 812 (1,090) Per person wealth, BOB 7,938 (6,129) 1,629 (916) 3,273 (4,243) Round trip travel time to market town, hr 16.7 (11.3) 10.1 (12.2) 11.8 (12.26) a Range = 67 123; SES = Socioeconomic status; BOB = Bolivian Boliviano ~ BOB$ 6.9: USD$ 1; Means (SD) are reported for continuous variables, percentages for categorical variables.
172 Table 4 2. Multivariable linear regression of inverted systolic blood pressure ( 1 / SBP) on socioec onomic status (SES), cultural c onsonance in life priorities (CCLP), interaction terms and covariates. Model A Model B Model C P P P Age 0.16 0.012 0.18 0.005 0.18 0.003 Female (1=female, 0=male) 0.41 0.000 0.41 0.000 0.40 0.000 Pregnant 0.13 0.045 0.12 0.048 0.13 0.035 Body mass index 0.23 0.000 0.24 0.000 0.22 0.000 Socioeconomic status 0.13 0.080 0.22 0.006 Cultural consonance in life priorities 0.15 0.044 0.16 0.030 CCLP * SES 0.20 0.008 Adjusted R 2 0.283 0.000 0.302 0.000 0.323 0.000 (height m) 2 ; SSS = Subjective socioeconomic status; CCLP = Cultural consonance in life priorities. Table 4 3. Multivariable linear regression of inverted dia stolic blood pressure ( 1 / D BP) on socioec onomic status (SES), cultural c onsonance in life priorities (CCLP), interaction terms and covariates. Model A Model B Model C P P P Age 0.19 0.005 0.20 0.004 0.21 0.002 Female (1=female, 0=male) 0.14 0.042 0.14 0.041 0.12 0.062 Pregnant 0.17 0.012 0.17 0.013 0.18 0.009 Body mass index 0.20 0.004 0.21 0.003 0.18 0.007 Socioeconomic status 0.08 0.339 0.18 0.042 Cultural consonance in life priorities 0.08 0.314 0.09 0.247 CCLP * SES 0.23 0.007 Adjusted R 2 0.157 0.000 0.157 0.000 0.184 0.000 Standardized regression coefficient; Body mass index (BMI) = weight kg / (height m) 2 ; SSS = Subjective socioeconomic status; CCLP = Cultural consonance in life priorities.
173 CHAPTER 5 CULTURAL CONSONANCE, SUBJECTIVE SOCIOECONOMIC STATUS AND HEALTH IN SOUTHEASTERN PUERTO RICO Overview There is a long history of research in medical anthropology to investigate the effects of acculturation on the health of migrants and to consider local health impacts of in sit u market integration and the culture change it engenders (McGarvey and Schendel 1986; Dressler 1999). A uniting aspect of this work is the finding that market integration leads to uneven change for individuals and corollary health inequalities in populati ons (McDade and Nyberg 2010). To comprehend the health inequalities that emerge from these processes we must investigate their underlying mechanisms. Research in the industrialized world has documented a social gradient in health that functions apart from absolute material deprivation ( CSDH 2008; Marmot et al. 1978 b ). Yet , some of the causes are not well understood. Due to the relative nature of the social gradient, psychosocial stress has been investigated as a key pathway tying it to health inequalities (McDade 2009). In particular, psychosocial stress is thought to result from a combination of increased status anxiety and reduced social support (Wilkinson and Pickett 2007). But analyses of the social gradient have fallen short of providing explanatory evidence because they frequently rely on the poorly understood variable of socioeconomic status (SES) as a proxy for a locally appropriate measurement of social standing despite its lack of commensurability across social structures (McDade 200 9). Two of the measures proposed for addressing this problem are subjective socioeconomic status (SSS) and cultural consonance (Adler et al. 2000; Dressler et al. 2005).
174 The recognized importance of SES as a predictor of health outcomes across industriali zed settings likely stems from its ability to capture certain salient aspects of status that reach beyond local contexts a more globalized form of common market based indicators of status. The practicality and intuition of SES therefore has to do with its ability to capture an important dimension of experience through readily measured variables. But as the importance of education, income and occupation vary by social structures, so too does the efficacy of SES as a lone status determinant of health (Sorens en et al. 2009). The nature of SES itself also seems more fluid than usually assumed, being at least partly shaped by cultural dynamics. Phenomena that have long been assumed to be universal could significantly alter how social gradients and relative depri gradient of illusory superiority highlights how the that was thought to be universal, in fact varies from society to soc iety and seems to be inversely proportional to the strength of shared beliefs about individualism (2007). Such local variation in the shared desire (or lack thereof) for conspicuous status would have important impacts on the relevance of SES. Subjective so cioeconomic status and cultural consonance both improve upon SES variables by using measurement models that are comparable across differ ent social structures. These approaches fit with evidence based recommendations for the need to improve measurement s of socioeconomic position (SEP) using context appropriate assessments (Bruna et al. 2006; Galobardes et al. 2006). The m easurement of subjective social status their place in the social ladder which takes into ac count standing on multiple dimensions
175 MRNSH 2007; Adler et al. 2000). It is operationalized on two levels with self anchoring scales of country (SSS) and community (Kilpatrick and Cantril 1960). At the socioe conomic level respondents are asked to indicate their relative rank among all others in the country on a ten rung ladder from worst off to b est off. At the community level respondents are asked to rank themselves relative to just those in their community. Subjective measurement s of status can therefore eliminate measurement error inherent to SES due to differences in local For example, in both the Whitehall II study in Britain and in CARDIA in the U.S., SSS explains additional variation in associations with health outcomes beyond standard SES variables for both global health and depression (Singh Manoux et al. 2003; Adler e t al. 2008). Cross cultural measurement of SSS , however, suffers from at least two important conscious awareness and at the whim of their willful denial (e.g. the level of respect, trustworthiness, or prestige assigned by others) and therefore cannot account for all variation in ascribed standing. Second, when SSS is used comparatively it does not consider variation in the cultural meaning and significance of equality an d social standing. As Marmot (2004) points out, the social gradient in health in not due purely to biology or society, but both. The presence of hierarchies throughout primate societies rchies are not inevitable or fixed. What it means to be high or low in a : 83). We need to better measure that meaning.
176 Cultural consonance expands on the intuition of SES and SSS by accounting for material, financial and int angible status markers while compensating for the difference in markers across settings and the very me aning of local relative status . In the domain of lifestyle, cultural consonance is defined as the degree to which individuals in their own beliefs and be haviors approximate the culturally valued conception of a good life encoded in the dominant cultural model (Dres sler and Bindon 2000). Cultural consonance operationalizes a timely and local empirical dimension of relative status that is not universally ac hievable by all people due to material, social and human capital constraints. Amartya Sen describes this type of status defines social inequalities linked to health inequity (1999) . Cultural consonance also accounts for local variation in the meaning of status markers and In the context of integration to markets and culture change, cultural consonance allows us to pinpoint key status markers that define hierarchy while avoiding measurement error due to temporal variation. Three examples of recent research highlight the usefulness of the consonance measurement model. Among a sample of African American youth in Chicago, Sweet (2010) found that low SES participants who most closely adhered to a high status cultural model had higher relative blood pressure while high SES youth with high consonance had the lowest overall blood pressure. Adherence to high status with little means, or striving, resulted in worse physiological outcomes for these youth. In markedly different contexts, consonance has also been associated with better psychological well being and fewer depressi ve symptoms in a panel study among
177 forager farmers in Bolivia and in a prospective cohort of socioeconomically diverse Brazilians (Dressler et al. 2007; Reyes GarcÃa et al. 2009). These associations are robust over time despite fluctuations in consonance a nd SES levels due to fluid local contexts. Longitudinal results, in particular, support the idea that cultural consonance in lifestyle and SES are distinct but overlapping measurement s . The stream of research on consonance demonstrates that both social a nd cultural measurement s of status are often necessary to elucidate underlying mechanisms of psychosocial stress. In t his study we add to research on the mechanisms of relative deprivation by comparing culturally salient status markers (consonance) to sta ndard socioeconomic indicators (SES) among a sample of participants f rom southeastern Puerto Rico. We also add to research on how perceptions of relative subjective socioeconomic status (SSS) might moderate the relationship between consonance and outcomes of psychological and physiological health (Singh Manoux et al. 2003; Demaka k os et al. 2008). Methods Research Site Research took place in the southeastern coastal town of Guayama, Puerto Rico. At the time of the work (2001) Guayama had approximately 44,00 0 inhabitants. A former key slavery port and agricultural center, today it is a relatively new hub of industry with a population that reflects its history including a wide range of socioeconomic diversity. Since the mid 20 th century most of Puerto Rico has undergone a dramatic transformation including rapid industrialization, internal rural to urban migration, and extensive emigration to the United States (Duany 2010). The impetus for much of this transformation lies in the explicit and unofficial polic ies of the
178 United States and Puerto Rican governments. The United States implemented Operation Bootstrap in 1948, which injected millions of dollars into the economy and, along with the Puerto Rican government, encouraged U.S. businesses to move their ope rations to the island. At the same time, Puerto Rico, with the support of the U.S. government, set up offices on the island and in the contiguous 48 states to promote the emigration of Puerto Rican workers due to overpopulation concerns (Duany 2010). All of this change coincided with dramatic increases in income inequality on the island. The income gap grew during the first 15 years after Operation Bootstrap despite initial rates of inequality in 1953 that were already higher than those in the U.S. and pe r capita income just 1/5 of the United States (Weisskoff 1970). Cultural Model of Lifestyle The study proceeded through progressively more structured parts in order to characterize the impact on health of the difference between individual beliefs and behav iors compared to a shared model of lifestyle. This included an initial formative period of participant observation by Gravlee, followed by cultural consensus analysis of li festyle (1986). Gravlee used the cultural key as the comparison template against which cultural consonance could be explicitly m easured . This approach results in rich contextual data built iteratively during ethnography and quantitative data that can be a nalyzed for associations with health outcomes. Participant observation narrow ed the scope of research and aided in the selection of key informants. ultural consensus analysis began with semistructured interviews, which fleshed out important top ics. Free listing activities exhausted knowledge and variation within the domain of lifestyle and he used structured
179 interviews to collect consensus ratings. Finally, he measured cultural consonance as well as psychological and physiological health outco mes and covariates in an epidemiologic survey. A variant of cluster sampling helped to maximize variability among respondents for the survey as described in detail elsewhere (Gravlee et al. 2005). Briefly, the clusters were based on neighborhood type incl uding, from lowest SES levels to highest, (1) caserÃos, or public housing facilities, (2) a lower class barrio on the edge of town, (3) a middle class urbanizaciÃ³n and, (4) a gated urbanizaciÃ³n. All local residents within the four selected neighborhoods w ho were at least 18 years of age were eligible to participant. Respondents in all phases of research gave written consent to participate. The Institutional Review Board at the University of Florida approved the research. Participant Observation and Interviews Gravlee carried out participant observation for 12 months. He wrote systematic field notes daily based on life in the study community and focused on insights related to culturally salient domains i ncluding lifestyle (Bernard 2011 ). Combined with open ended interviews and free listing this approach helped narrow the scope of research during later structured data collection without losing site of local ly novel dimensions of status. He drew purposive samples for free list elicitations ( N =30) and str uctured interviews ( N =20) to maximize variability on important characteristics. Sample sizes were based on numbers found sufficient to exhaust important themes in previous research (Weller and Romney 1988; Handwerker and Wozniak 1997). Consensus Ratings Gravlee recruited a fres h sample of 15 participants for s tructured ratings interviews. He evaluated f orty two items fr om consolidated free lists for their
180 importance of defining someone as a success in life on a three point scale of important He analyzed these ratings for consensus using UCINET software to evaluate (1) whether a single cultural model was present, (2) the cultural knowledge of each respondent, and (3) to determine the cultural answe r key for the most appropriate responses. Consonance One hundred respondents were surveyed from four distinct neighborhoods as described briefly above and in detail elsewhere (Gravlee et al. 2005). Gravlee measured responses to yes or no questions of own ership of material goods and analysis ( N =20). We calculate consonance scores as the proportion of 20 items greater ed, by each respondent. Covariates and Health Outcomes We determined socioeconomic status by factor scoring of a principal components analysis based on household income and years of education. We constructed this composite variable to prevent multicollinea rity due to overlap of income and education when entered as independent variables. Subjective socioeconomic status both within the local community and within Puerto Rico was self assigned by respondents who Gravlee presented with a standardized 10 step lad der where 1 represented the lowest social position in society and 10 indicated the highest. Gravlee used a translated version of the 10 item Cohen and colleagues P erceived Stress Scale (PSS) reports of stress (1988). The scal e is commonly used in stress research and Spanish language versions of the instrument have tested well elsewhere in Latin America (RamÃrez and HernÃ¡ndez
181 2007; RamÃrez and HernÃ¡ndez 2008). Psychological distress and blood pressures were the primary research outcomes. He used the Center for Epidemiologic Studi es Depression Scale (CES D) to measure depressive symptoms (Radloff 1977). The CES D is a 20 item self report checklist that elicits c ommon symptoms of depression. Gravlee also administered a translate d and previously validated version used elsewhere in Latin America and Puerto Rico ( Ruiz Grosso et al. 2012; Vera et al. 1991) . We analyzed the square root of the CES D score in the statistical models to adhere to assumptions of normality. Blood pressure was determined by averaging three measurement s taken after respondents had been seated for at least 10 minutes. Gravlee measured blood pressure with an automatic monitor to further limit measurement bias (Omron Model HEM 737 AC; Omron Healthcare Inc., Vern on Hills, IL; Anwar et al. 1998). We model both systolic and diastolic blood pressures using inverted measurement s (1/DBP and 1/SBP) to adhere to analysis assumptions of normality. We calculate body mass index (BMI) from height (cm) and weight (kg) measure ment s. Gravlee determined the use o f blood pressure medication by self report. We used multivariable regression analyses to examine the relationship between (a) blood pressure and cultural consonance in lifestyle, (b) CES D and cultural consonance in life style, c) blood pressure and SES and, (d) CES D and SES, while controlling for covariates of age, sex, BMI, and blood pressure medication (when appropriate). Finally, we assessed potential moderators through cross product interaction terms including the PSS, community SSS and Puerto Rican SSS (we only include significant interactions below) .
182 Results Consensus model of successful lifestyle. The eigenvalue ratio of the first two factor s, used to evaluate consensus, was 5.7:1. This surpasses the established minimum threshold of 3:1 (Weller and Romney 1988). Factor analysis of similarities among informants suggests a single underlying dimension explained about 78 % of the variance in how informants rate items as important to having a successful lifestyle. In all, 42 unique create the cultural consonance survey module. The top 20 lifestyle indicators are list ed in Table 5 correlations with the model) and the percentage of informants who reported each indicator. or speaking English were among top rated indicators in addition to material items such as owning a cement house or a land based telephone. Consonance and Health O utcomes Total and neighborhood stratum sample characteristics for survey respondents are list ed in Table 5 2. Gravlee collected each 25 person cluster sample in a distinct neighborhood. C luster sample size was not based on total population of each neighborhood, which resulted in over representation of females in the total sample particularly due to a disproportionate rate of female s in the CaserÃos neighborhood. Mean perceived stress scores (26.4) did not vary between strata in the sample. Perceived stress was positively associated with depressive symptoms when included in regression models (not p ictured) including with consonance as an explanatory variable
183 and separately with SES. The association of PSS with outcomes did not reach significance when regressed on SBP or DBP. Based on stress process theory, we tested PSS as a mediator but it failed t o meet criteria in any of the models (Baron and Kenny 1986; Dressler 2007a). Dressler et al. have reported similar results in their research on cultural consonance (D ressler et al. 2005). The models we present in T ables 5 3 and 5 4 therefore do not include PSS. Neither significance nor effect size varied substantially after its exclusion. We found that sample income and education levels were higher than average in Puerto Rico due to a quarter of the sample coming from a high income neighborhood as part of t he cluster sampling strategy to maximize variation. These variables, along with Puerto Rico SSS and community SSS, showed significant variance between sampling strata. Overall, respondents reported they had higher relative ranking (6.9) in their community than in Puerto Rico (6.0). The average weighted cultural consonance in lifestyle score on a scale of 1 3 was 1.3 ( Â±0 .3) with significant d ifferences between strata. Depressive symptoms measured with the CES D averaged above a clinically suggestive cutoff ( 1977). The rate of hypertension in the sample was 18 % , 8% lower than the prevalence for all of Puerto Rico in 2001 (CDC 2001). Average BMI was 28.6 , which is substantially higher than the average of 22.2 for all of Puerto Rico in 2001 (CDC 2001). Due to the high correlation of consonance and SES in the sample (90.5 % ) , we included subjective social status at both the community (not shown) and island level (SSS; shown) to test these potential ly important separate dimensions of status.
184 Our multivariable regression analyses of SBP, DBP and CES D on consonance and covariates (except interaction terms) all produced the expected inverse association with cultural consonance but the association was only significant between consonance and CES D. We include this model for D in Table 5 3. Separate multivariable regression analyses of SBP, DBP and CES D on SES and covariates (except interaction terms) had the expected inverse associations with hea lth outcomes and all were significant (SBP and DBP shown as inverse in models; p<.05) . Before inclusion of interaction terms, effect sizes are similar for CES D on SES ( 0.54; not shown) and CES D on CCLS ( 0.50; shown). However, neither SSS in Puerto Rico or relative community status were significantly associated with any of the health outcomes in the initial models for CCLS or SES. We tested health outcomes against the c ross product interaction terms of SSS*CCLS and SSS*S ES in their res pective models. The interaction was significantly inversely associated with SBP (Figure 5 1) and positively associated with CES D (though the association did not reach significance) . The SSS*CCLS interaction on SBP results in an effect on SBP only for th ose with high SSS (>5; n = 62 ) versus low SSS n = 38) . The size of this effect is over four times as large as the effect from SES in separate models ( =1.06 versus =0.23). The nature of the effect is that those with high SSS but low CCLS have the worst SBP in the sample and those with high SSS and high CCLS have the best SBP in the sample (Figure 5 1). For CES D there was a direct significant inverse association between CCLS and CES D (see Figure 5 2). For both low and high SSS groups , higher con sonance was correlated with fewer
185 depressive symptoms. The meaning of these findings and their possible mechanisms are discussed below. Discussion In this article, we demonstrate that our measurement of culturally salient status markers (CCLS) is inversely associated with depressive symptoms in a sample from four urban Puerto Rican neighborhoods. We also find that CCLS interact s with self perceptions of social status in Puerto Rican society to moderate SBP among some participants in the sample. Those who self assessed as having high SSS relative to Puerto Rican society suffered higher SBP when their SSS was incongruous with their CCLS. This result reveal s that both local cultural status and societal relative position matter for cardiovas cular health in this sample but only after a particular threshold of SSS. Our data are insufficient to predict an exact threshold but this result deserves more investigation. Our findings also point out that analyses of just SSS or CCLS status measuremen t s could lead to false associations due to omitted variable bias (Wilkinson and Pickett 2007). Local C ultural M odels and I ndividual C onsonance in L ifestyle The finding of a close alignment between cultural consonance and SES empirically shows that the Pue rto Ricans sampled have incorporated status indicators of education and household income into their local status models. Despite this, the additional cultural detail contained in our CCLS measurement was ultimately able to better explain an important unde rlying mechanism of the gradient in health present in the sample. Analyses comparing CCLS versus SES show that both have similar associations with CES D and effect sizes though the SES model explains more variance (SES model is not shown; R 2 =0.335 versus C CLS model R 2 =316). Our results
186 suggest that neither a self assessment of SSS nor a standard indicator of SES is alone sufficient in this population to capture the underlying nature of asso ciations with health outcomes. In fact, standard regression analysi s without SSS interaction terms gives the misleading result that consonance might work in the same (if attenuated) way as SES . When interaction terms are included, however, it becomes clear that consonance is a buffer against perceptions of high personal s ocioeconomic status (SSS) that is not otherwise positively associated with poor health. The S tress of C onflicting S tatus E xpectations In our consensus analysis of the lifestyle domain, four of the top five most culturally agreed upon indicators reflect dim ensions of material and human capital status. That is, while items lower on the list such as stove, refrigerator, bed or a shower and speaking English have multiple dimensio ns of meaning that are at once practical and also status based. In this way , cultural consonance may affect health through This matters unities to approximate shared ideals are not evenly distributed. In all settings, this results in social stratification along salient lines of knowledge. Data shows that s ocial stratification due to income and wealth inequality in Puerto Rico hit a peak in 1969, receded some in the next two decades and then exceeded all previous recorded levels in 1999 around the time of the research (Sotomayor 2004). Similarly, on the isla nd of Samoa, different rates of industrialization were found to cause conflicts in cultural and social status markers (McDade 2002).
187 In a market system, symbolic status based only in part on material wealth can become more important that absolute wealth . With relative deprivation theory to inform our modeling, we included two self assessments of social status to test this dimension. second asked for their status relative to all of P uerto Rico. These differences can lead to status hierarchies and corollary disparities in mental and physical health due to psychosocial stress for those who cannot live up to local and extra local expectations. Standard socioeconomic markers, however, ar e only good measurement s of a portion of what typically makes up social status (e.g. formal education and yearly income). They also can miss the local relative importance of these status markers. Positions in different status dimensions are not equally salient or independent from one another (Vernon and Buffler 1988). constructivist version of the stress process as a guide, low CCLS can be considered a potential source of psychosocial stress that falls between shared models of status, social support and structural constraints on one side and physiological and mental health outcomes on the other (2007b). The significant interactive effect of SSS in Puerto Rico compared to SSS in the community implies a greater salience for this outward looking assessment. that relative deprivation often matter s more for health than absolute income lev els. The finding of a moderator effect between cultural consonance and subjective socioeconomic status in Puerto Rican society demonstrates how both local expectations T he
188 result for this Puerto Rican sample is physiological health inequalities for those who cannot align with both local and extra local expectations. The rapid pace of change in Puerto Rico over the last 60 years is the most likely explanation for this sign ificant inter action in the data. Therefore, we conclude by presenting examples from a re analysis of qualitative data that explores this possibility using semistructured interviews from participants who reported experiencing status incongruities first hand . For Operation Boots t Even though we come from very poor people, we strove, we went to school, looked for good jobs, in m y case I looked for a good job, I was a good provider for my family. And speaking about those who lived beyond their means: I saw that example in my coworkers. The colleagues of mine at work making so much more money than I earned and filing for bankruptcy to avoid paying. They took loans, and got homes, and got cars, and got money. I worked for my family. If my family ne eds it, then here it is. But not to waste it. Because really, wow, after you kill yourself working ... (interview 02; translations by the authors) On the whole, respondents describe people who are culturally dissonant but report high SSS as having their co nceptions of success threatened by the ideologies of free markets and rapid globalization on the mainland; including those of conspicuous consumption and excess. Conversely, culturally consonant persons those concerned with living more modest material liv es while maintaining local values were described as tend ing to reject the desire for overt displays of wealth and prioritization of global imaginaries of status ahead of family priorities. These perspectives on status incongruities make sense as potential sources of psychosocial stress in everyday life.
189 Overall, the qualitative data may also explain why SES is problematic as a lone status marker among this population. It can only serve as an indirect link between neomaterial and symbolic status dimensions and health and does not adequately address self assessed status . To ameliorate this shortcoming, our work effectively draws operational distinctions between theoretically different components of status through a novel analysis of SSS and cultural consonanc e. Subjective socioeconomic health (Adler et al. 2000) . Meanwhile, cultural consonance research finds that how other people perceive you matters for your health (Dressler 2012) . This is the first study, to our knowledge , to simultaneously evaluate SSS and cultural consonance. The study makes a contribution to research on relative deprivation and health by demonstrating that a culturally specific variable of lifestyle can be used in conjunction with global variables of SES and self perceptions of status to better elucidate the mechanisms that cause psychosocial stress and related poor health outcomes in the context of change. Much more work is needed to further assess and verify t he importance of cultural consonance as an explicit cultural determinant of health. Limitations This research explains variation for outcomes among a cluster sample but it should not be considered representative of the local population. Also, our SES vari able was based only on income and education. It did not include a measurement of occupation. This may have resulted in measurement of only one dimension of SES.
190 Figure 5 1. I nteraction of high (>5; n =66) and low (<6; n =34) subjective socioeconomic status (SSS) and cultural consonance in lifestyle associated with systolic blood pressure and controlled for age, sex, BMI, and antihypertensive medication.
191 Figure 5 2. Square root of depressive symptoms (CES D) regressed on cultural consonance in li festyle controlled for age, sex, BMI and SSS (bars are 95% confidence intervals ).
192 Table 5 1. Cultural model of lifestyle . Lifestyle i tem Weighted average of consensus rating a from key informants Percentage reporting behavior or owning item To own a cement house 2.94 97.00 To have a high school degree 2.93 81.00 To own a car 2.88 84.00 To speak English 2.87 43.00 To have a bachelor's degree 2.87 32.00 To own a stove 2.86 97.00 To own beds 2.84 100.00 To own a shower 2.74 98.00 To own a refrigerator 2.69 99.00 To own a land based telephone 2.64 80.00 To own a washing machine 2.40 95.00 To have air conditioning 2.26 59.00 To read the newspaper 2.19 44.00 To own a personal computer 2.19 55.00 To own a television 2.13 99.00 To take a vacation 2.13 44.00 To have a dining room 2.04 89.00 To have a credit card 2.02 43.00 To own a cell phone 1.99 79.00 To belong to a social club 1.95 20.00 a W eights are based on the cultural competency levels of the 15 key informants .
193 Table 5 2. M eans (Â±SD) or percentages for major variables, for total sample (N = 100) and by sampling cluster (n = 25) a . Variable Total sample CaserÃos Barrio Open urbanizaciÃ³n Gated urbanizaciÃ³n Cultural consonance*** 1.3 (0.3) 1.0 (0.2) 1.1 (0.3) 1.5 (0.1) 1.7 (0.1) Puerto Rican SSS*** 6.0 (2.0) 4.4 (1.7) 5.3 (2.4) 6.8 (1.1) 7.4 (1.2) Community SSS** 6.9 (2.0) 5.7 (2.4) 7.1 (2.0) 7.3 (1.5) 7.3 (1.5) Perceived stress s cale 26.4 (6.3) 28.2 (6.9) 27.3 (7.2) 25.4 (5.9) 24.8 (4.9) Systolic blood pressure 125.4 (17.4) 124.4 (17.9) 126.5 (20.4) 129.7 (18.2) 121.0 (11.7) Diastolic blood pressure 80.1 (10.6) 80.6 (9.1) 79.0 (11.3) 83.2 (11.9) 77.6 (9.5) Depressive symptoms*** 13.7 (10.8) 18.7 (10.0) 16.2 (10.9) 12.5 (11.3) 7.2 (7.8) Body mass index 28.6 (6.1) 27.4 (6.3) 27.4 (6.5) 29.6 (5.6) 29.9 (5.8) Age 39.2 (8.0) 38.2 (8.2) 38.7 (10.0) 39.9 (8.0) 40.1 (5.3) Sex (% female) 62.0 84.0 56.0 56.0 52.0 Education (years)*** 14.1 (3.6) 10.9 (2.8) 12.4 (3.4) 15.7 (1.5) 17.5 (1.9) Household income (imputed)*** 37,995 ( 35,536) 6,120 (1,666) 19,200 (19,421) 35,160 (16,117) 91,500 (12,353) Antihypertensive medication (%) 10.0 8.0 4.0 8.0 20.0 a Tests of significance for neighborhood difference by ANOVA for continuous variables and by chi square for categorical variables *P<0.10; **P<0.05; ***P<0.001; SSS = Subjective socioeconomic status
194 Table 5 3. Multivariable linear regression of cultural consonance in lifestyle (CCLS), subjective socioeconomic status (SSS) and covariates on inverted blood pressure (1/SBP and 1/DBP) and s quare root of depressive symptoms D). Table 5 4. Multivariable linear regression of standard socioeconomic status (SES), subjective socioeconomic status (SSS) and covariates on inverted blood pressure (1/SBP and 1/DBP) and square root of depressive symptoms D). 1 / SBP 1 / DBP D p p p Age 0.45 0.00 0.35 0.00 0.14 0.09 Male (male=1, female=0) 0.28 0.00 0.07 0.43 0.05 0.56 BMI 0.10 0.24 0.16 0.09 0.11 0.21 Antihypertensive medication 0.22 0.02 0.22 0.02 . . Puerto Rico SSS . . . . 0.01 0.93 SES 0.23 0.02 0.26 0.01 0.93 0.00 Puerto Rico SSS x SES . . . . 0.38 0.15 Adjusted R 2 0.311 0.00 0.197 0.00 0.343 0.00 2 ; Intentionally left out of the model. 1 / SBP 1 / DBP D p p p Age 0.43 0.00 0.33 0.00 0.19 0.03 Male (male=1, female=0) 0.23 0.01 0.03 0.77 0.11 0.20 BMI 0.12 0.19 0.16 0.10 0.10 0.26 Antihypertensive medication 0.20 0.02 0.20 0.03 . . Puerto Rico SSS 0.65 0.04 0.35 0.31 0.06 0.57 CCLS 0.33 1.00 0.16 0.60 0.50 0.00 Puerto Rico SSS x CCLS 1.06 0.03 0.67 0.24 . . Adjusted R 2 0.313 0.00 0.170 0.00 0.316 0.00 2 Intentionally left out of the model.
195 CHAPTER 6 CONCLUSION In this conclusion I review my findings and attempt to place them in the ir local and regional context . I also consider how the findings fit with the overall aims of the study including their implications for cross cultural research on social status and psychosocial stress . To start , I address the three questions that emerged from my pilot project on social networks , status and market integration in 2010 first posed in the introductory chapter of this dissertation . These questions are less applicable to the Puerto Rico study so I postpone my summary of those findings until the review of my overall research aims later in this chapter . M y pilot project raised several questions regarding status and market integration with the most important being , (1) What is the basis of relative perceptions of c onceptions of status? And, (3) Why have changes in shared conceptions of status or resulted in severe social gradients despite over twenty years of in situ market exposure? Basis of relative perceptions of status and traditi on communities . The concept of conspicuous social status is not easily translated to the a group of forager horticulturalists most closely approximate such a n overt hierarchy only in their kinship structure . In my participant observation and semistructured interviews, I found social status to be much more nuanced likely owing to a context where almost everyone know s everyone else, is related to most of them and has spent their entire lives living around them . commonly used to denote the group ,
196 loosely translates to a mixture of relative and brethren. Kinship patterns , however, do provide clues as to the construction and extent of social status. For example, it has long been traditional cultural practice for parents to arrange marriages for their children , a custom that keeps power within the family and adult children from straying too far (Huanca 2008) . Recently, however, the power of parents and influence of family interests over individual interests have been put into flux. Many adult children are moving away from their birth villages, freeing them to make decisions about the future that do not involve consideration of t heir entire extended family. At the same time , g ender roles have not shifted much. For example, the traditional cultural practice of m en taking on leadership positions within and outside of the family has largely been maintained . Examples of women taking on such roles are, as yet, still novelties. In the past, households would have balanced these gender roles some by obey ing matrilineal residence patterns so that new husbands went to live with their parents . Under this arrangement a new husband was the head of his family but a new wife also had her father to balance power in the shared household . With this pattern changing, however, there are at least as many n ew families that no longer practice matrilineal residence , instead preferring to build thei r own houses . F requently , these new homes are located next , creating power asymmetries for women who no longer have their fathers to stand up for them as new wives in a patriarchal society . Other components of status besides g ender and family relations are also being affected by change including traditional status components such as age and skill at things like hunting, fishing , farming, craft making , medicinal plant use and canoe
197 building ( Kightley et al. 2013 ; Reyes GarcÃa 2001 ) . Teachers and community magistrates have also come to play important roles over the last couple of decades but are not uni versally respected and valued especially now that many teachers are Spanish speaking non outsiders . I ncreasingly , with more income from sales of crop s and crafts , contracts and wage work, certain market items like electric generators , canoe motors and televisions have become sought after . To capture the most current basis of important status components I built a model of life priorities by categorizing what mattered most to people in order to live a good life in their communities . Through this model I tried to capture aspects of life that go beyond overt status markers to also encompass the values and priorities of the culture as a whole including things from everyday life and the emphasis on family . My ethnographic and semistructured data both showed that obligations to family and family support were some of the top priorities and sources of social support . This means that family was often made a priority over other intangible or material things in life. Table 3 3 summarizes the results of my cultural consensus analysis of life priorities. W ithin just These culturally meaningful categories are also indicator s of likely change . For example, i n the isolation of Serruch o , were strong priorities while in the more market integrated AjÃ , they were not . Combined with the results of my cultural consensus analysis of social support summarized in Figure 2 2 and Table 3 4, the locally important aspects of a good life are a critical part of social status and resistanc e resources. Social status among the is a dynamic and cultura lly meaningful state of being with a heavy emphasis
198 on family in both life prio rities and social support. To achieve high status as a is to be highly culturally consonant with t hese family priorities . As a testament to this reality, Figure 4 5 (which summarizes average consonance for life priority items in Aj Ã and Serrucho ) shows that getting along with family is one of the most consonant items overall . In this area of life, it s eems, most people both profess the importance of family and make them an actual priority. T o get along well in the world getting along with your family. The relationship of market integration to local conceptions of status . Beginning with my ethnographic data, it is social status are in flux both within and between communities . As explained in detail in Chapter s 2 and 3 , this is revealed in a loosely shared conception of life priorities b etween my ethnographic study communities , Aj Ã and Serrucho. It is also related to strongly held agreement in the domain of social support. For both life priorities and social support, there was a core set of items agreed upo n strongly enough to represent s hared cultural domain s in the agreement between first factor s . However, there was also a strikingly clear distinction between Aj Ã and Serrucho along the second largest latent factor s for the two domains . This residual agreement was split in both domains along community lines . In both cases, an analysis of this deviation between the communities based on specific items in the domains showed that r esidents from Serrucho support ed additional life priorities and forms of social support ( Figure 3 4) . My analysi s of the contents of this deviatio n in Chapter 3 showed that all but one of the se additional items were of long held s ymbolic cultural significance (e.g. forest medic ines
199 tied to native metaphysics and patterns of social organization such as cross cousin marriage practice and maintaining a home in your birth village) . I conclude that the most likely explanation for this split between the communities is the increased level of market integration in Aj Ã that comes in the form of changing life priorities not exclusively higher SES since this measure was actuall y highest overall in Serrucho including important change in the meaning of who and what matters . Whatever their ultimate cause (s) , the differences identified result ed in reduced importance for several tr aditional cultural practices and symbols in Aj Ã . This result fit s with theory on the process of commoditization during market integration that predicts the very meaning of basic life components like labor and social support will shift (Lu 2007 ). The implication for the study of market integrated societies and social status is that the change in composition and meaning of life priorities appear to be at least as important as the occurrence of actual material change (i.e. higher incomes and wealth allowing for more modern market items). The lack of severe social gradients due to in situ market exposure among the . As documented by other researchers, income and wealth inequality do not yet seem to be important causes of health disparities for (Undurraga et al. 2010). Yet, there are examples that income inequality may matter beyo nd basic material necessities. I n Serrucho , for example, where incomes and wealth are relatively high , I found that residents were also the most capable of any in the eight survey communities of approximating the model of life priorities . Figure 4 5 shows consonance levels for each domain item for residents from Aj Ã and Serrucho including several that would be expected to improve with higher incomes (e.g. Having enough market tools
200 and materials). The high average level of consonance in Serrucho was also matched by some of the best health outcomes for blood pressure and BMI overall in the survey . All of this occurred in a context in which Serrucho was able to maintain additional life priorities beyond those in Aj Ã that almost all corresponded to traditional cultural priorities. While limited, this benefitted from balance betwe en incr easing income and wealth and maintenance of traditional cultural practices related to family and social support that act as buffers against psychosocial stress . Despite some serious skew in the SES distribution in the epidemiologic survey (Figure 4 2) that shows just a small number of relatively wealthy households, overall study results showed that those with low SES had very healthy average blood pressures. In fact, the worst health outcomes were recorded for people with high SES and low cultural co nsonance. Therefore, the only important gradient uncovered in my data was based on relative levels of CCLP. Review of Study Aims With this dissertation I set out to address the three key study aims listed below. I now summarize my findings regarding these aims and lay out the implications for future research regarding the cross cultural st udy of social status and health. Study Aim 1: To Understand the and Social Stratification My results paint a complex picture of ch a nge. For women and the elderly living close to market towns, and young children and youth living in remote villages increasing market integration is having very mixed effects. Other researchers have shown that the
201 in part to better vaccinations and new government social security programs ( Nyberg 2009 ). In the case of the elderly and women , howe ver, I heard consistent report s of more suffering due to reduced social support from those living near market towns. In Chapter 2 I detail accounts from AjÃ of this reduced support due to increasing demands on spouses, fathers and sons, many of who m now work for wages or attend schools outside of their communities . My qualitative study of change, challenges, resources and social stratification (Chapter 2) makes it plain that there is a gendered experience of market integration in both AjÃ and Serru cho . In AjÃ this occurs because many young men have either left to further their education outside of the community or are rarely around due to wage and contract work with outs iders elsewhere . This leaves women alone to manage both the agricul tural plots a nd children . In Serrucho , many young men work logging contracts that take them away from home for w eeks or even months at a time. This means that w omen must either stay behind in the community with their children if they want to continue to tend an agricul tural plot, or travel with their spouses, taking young children with them and leaving older children and crops behind. Using the final model from my analysis of consonance and sys tolic blood pressures (Chapter 4 ) I find that across all eight communities physiological outcomes are gendered as well. M en share d much higher adjusted blood pressures close to a full standard deviation for SBP (1 SD = 15.25mm Hg; see Figure 4 4 ). Cultural consonance in life priorities seems to buffer against stres s for men and w omen equally , but average blood pressure stratified by gender is much lower for women than men across all age ranges. Potentially because of the oversampling of acce ssible versus
202 remote communities in my survey ( n =142 versus n =67) which migh t be expected t o result in worse experiences for women men had consistently highe r blood pressures throughout all eight communities. This suggests that men are already experiencing more stress from commoditized wage and contract work a possibility that should be explored further in future work. Study Aim 2: To Describe Consensus and Variation in Cultural Models due to Market Exposure The cross sectional design of my epidemiolo gic survey does not allow me to explicitly test market exposure in th is dissertation. In stead, I relied on long term participant observation and the proxy measure of community distance to market , which other researchers have established as a reliable measure of market exposure in this setting (Undurraga et al. 2010; Gurven 2004) . Living as a resident in the communities for extended periods of time and learning to speak the language made me aware of the inflows and outflows of peopl e , ideas and material items overtime. I t was also helpful to switch back a nd forth between Aj Ã and Serrucho over my two years in the communities because it provided a comparative lens for my observations and experiences. The consensus results that I found in social support and life priorities did not come as a surprise . If anything, it was the clear distinction between communities in the residual agreement of the second factors of these domains that actually surprised me . The conclusion I draw from these outcomes is that the residents of AjÃ reject many traditional Tsim cultural beliefs and practices because they have begun to more readily adopt priorities and practices common in larger Bolivian society . I n AjÃ, for example, I had many interactions with residents who were eager to tell me about how
203 modern their lives were and how they rejected the old religion and ways as confused and wrong . The re are alternative explanations, of course. The most likely is a self selection bias on the part of people who cho se to move to AjÃ. If this is the case and it surely is for at least a few residents for most residents then the cause of the variation is not only market exposure acting on residents in situ but an endogeneity or other bias that would be difficult to specify . Even so, such a bias would only explain the difference in agreement for newer residents in AjÃ not life long residents . I n exploring the potential impact on my results of this possibility, I found no obvious d ifferences between new and olds residents or in the other communities in the epidemiologic survey with varied levels of market exposure and migration patter n s . Still, a more systematic comparison would be a helpful next step to determine the effect of a possible self selection bias. Study Aim 3: To Compare C onsonance in a Non Forager Horticulturalists versus an Industrial Society of Urban Puerto Ricans Chapters 4 and 5 are studies of the results of the epidemiologic surveys among Among 209 survey communitie s with different levels of market exposure, I found an inverse association between levels of CCLP and blood pressures. Additionally, SES interacted with the association between blood pressure and CCLP such that the blood pressure of those with high SES was most affected by levels of CCLP, both negatively and positively, whereas the effects of CCLP were mostly attenuated for those with low SES . In this way, CCLP seems to act as a buffer against high blood pressure for those with high SES. T his buffering e ffect is mostly attenuated for all those with low SES.
204 In Chapter 5 , along with my colleague Clarence Gravlee, I analyze d data from four economically distinct neighborhoods in the urban municipality of Guayama, Puerto Rico. In this data we find a similar i nverse relationship between blood pressure and the interaction term between CCLP and SSS. The result is that CCLP only acts as a buffer against high blood pressure for those with high SSS (>5 on a scale 1 10). We also test ed the association between CCLP an d CES D and found an inverse association between CCLP and CES D. Higher consonance in the Puerto Rico sample was correlated with fewer depressive symptoms. Direct comparison of the two study sites is difficult due to the extreme differences in day to day l ife in each setting . Despite this , in cultural consonance we have a measurement model that allows for a cross cultural comparison of the domain of a good life measured as among the Puerto Rican sample . This facilitates a comparison of the importance of cultural expectations and how approximations to these affect health outcomes in the face of different levels of market integration . The conclusion I draw from comparing these results is that consonance seems to act as a psychosocial buffer in each of these settings . Importantly, consonance also seems to be most important to health, not for those with low SES or low SSS, but people wi th relatively high SES or high SSS. In both settings, the proposition of seeking higher SES or higher SSS is a double edged sword in that those who manage to attain high SES or high SSS but fail to match this with high cultural consonance actually suffer the worst health outcomes. That is, in the studies they not only lost the positiv e stress buffering effect of consonance but actually suffer ed health worse than even those with both low
205 consonance and low SES or low SSS . This negative result matches research on other cultural incongruities where outsize suffering is caused by failure t o maintain both cultural and socioeconomic expectations (McDade and Nyberg 2010) . It is unique, however, in that the effect seems limited to only high SES and high SSS individuals. Implications for Cross Cultural Research on Social Status and Psychosocial Stress T his dissertation make s three key contributions to the literature on social status and psychosocial stress. (1) The findings on consonance and health among the are some of the first from a non industrial population with minimal integration to the market economy. This provides a unique perspective on the functioning of the cultural consonance measurement model and social status itself under circumstances where SES and market based forms of inequality have b een shown to have little effect on health (Undurraga et al. 2010). The unique construction of the consensus models for life priorities and social support are all the more intriguing because cultural consonance in this setting did not serve as a ve ry effective buffer against stress related health outcomes for those with low SES. Still with high SES and low consonance, their average blood pressure s never reach ed a level of clinical significance . This could mean that among the the lower priority of SES results in a less severe social gradient or that other aspects of their culture like family and social support act effective ly as a stress buffer, or both. (2) The results from my semi structured and structured analyse s are also unique because they were collected among non industrialized forager horticulturalists cu rrently undergoing rapid change in a setting that has been shown to act as a good proxy for market exposure. Thanks to increasing levels of geographic isolatio n as distance to market increasing, the qualitative effects of
206 market exposure can be reasonably estimated . This allows me to draws conclusions about the qualitative nature of change due to different levels of market exposure including the effect it has ha d on the meaning of a good life and social status. Combining this work with structured data on cultural consensus models revealed some munities due to market exposure. (3) The fin dings from the epidemiologic surveys in Bolivia and Puerto Rico provide a unique juxtaposition for comparing the experience of social status in a non indus trial versus industrial setting . By presenting both studies within the context of their unique political economic histories I try to elucidate what status has come to mean in each setting, not just because of local and cultural expectations but regional, national and international as well. In the case of the , social status is bound to local life priorities, especially family . For the Puerto Rico study, conspicuous industrial setting also eliminates the choice of living a market free autarkic life , which forces everyone into one form or a n other of wage or salary work. The stress of industrial society shows up in the overall higher average blood pressures and reports of depressive symptoms among the Puerto The consequences for those with low cultural consonance in Pue rto Rico also reach levels of clinical significance for blood pressure and CES D. Summary In this dissertation I have analyzed data from a diverse set of largely self sufficient forager horticulturalists and urban Puerto Ricans . Their life experie nces, due to ongoing market exposure, provide helpful insight into the likely health effects of meaning on social status and social support . The conclusions I reach in my data chapters suggest that rapid change is having a dramatic effect on shared
207 Tsimane resistance resources are most important and who suffers most from psychosocial stress . To be sure, the data I analyze here cannot prove causality and therefore must be interpreted with caution as exploratory results. While I did find culturally shared models of life priorities and social support, the content analysis of these models and the wide variation in success of their approximation suggests shifting meaning s in these domains. Many q uestions remain regarding the process of market integration, the changing of social status and psychosocial stress. Future work would benefit from longitudinal data that could connect cultural consonance to psychosocial stress over time. There is al so a need for more targeted measures of the physiological stress response that could be incorporated into consonance research to gain insight into how meaning affects status and the stress process .
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236 BIOGRAPHICAL SKETCH Alan F. Schultz graduated from Kennedy High Schoo l in Cedar Rapids, IA in 1998. He later attended the University of Iowa in Iowa City, IA where he graduated in Spring 2004 with a Bachelor o f Arts degree in anthropology. Alan next attended the University of Iowa, College of Public Health in Iowa City, IA graduating in Spring 2006 with a Ma ster of Public Health degree focus ed on epidemiology. In June 2006 he was appointed a fellow of the California Epidemiologic Investigation S ervice (Cal EIS) , serving for two years until mid 2008 . Alan worked with the Cal E IS at the Office of AIDS , California Department of Public Health, Sacramento, CA as an employee of the Tager Colford Research Group at the University of California, Berkeley , School of Public Health. In F all 2008 he began graduate studies in medical anthropology under the guidance of Clarence C. Gravlee at the University of Florida in Gainesville, FL. He received a Ph.D. in anthr opology in August 2014. In Fall 2014 he became t enure track assistant professor in the D epartment of A nthropology at Baylor University in Waco, TX.