Stanley Krippner, Ph.D.
The term “ethnomedicine” refers to the comparative study of medical systems, focusing on beliefs and practices concerning sickness and health in different human populations. It observes and describes hygienic, preventive, and healing practices, taking temporal and spatial references into account.
Typical ethnomedical topics include causes of sickness, medical practitioners and their roles, and specific treatments utilized. The explosion of ethnomedical literature has been stimulated by an increased awareness of the consequences of the forced displacement and/or acculturation of indigenous peoples, the recognition of indigenous health concepts as a means of maintaining ethnic identities, and the search for new medical treatments and technologies. In addition, Kleinman (1995) found ethnographic studies an “appropriate means of representing pluralism...and of drawing upon those aspects of health and suffering to resist the positivism, the reductionism, and the naturalism that biomedicine and, regrettably, the wider society privilege” (p. 195).
Puerto Rican Folk Healing
My interest in ethnomedicine was stimulated by a visit to a public community mental health center in Cayey, Puerto Rico in 1979. I had been informed that mental health professionals had been meeting with spiritistically-oriented folk healers twice a week for several years, and I was invited to sit in on one of the meetings. I was told that the first week of encounters had been devoted to lectures by representatives from both groups, while the second week focused on case conferences in which both groups gave input in regard to clients seen at the center. From this point on, the folk healers were accepted as members of a team that typically included a physician, a psychologist, and a social worker. Sometimes a psychiatrist was available for consultation as well. When I was there, the topic was what use to make of the clients' dream reports; the folk healers used them to identify the “helping spirits” of the clients, while the mental health professionals utilized them to understand the clients' conflicts and problems. The group agreed that these two purposes were not contradictory.
Koss (1979) conducted a research study of this process, concluding that the folk healers were highly motivated and committed to their work. She also noted that their approach to therapy was more emotionally charged than that of Western-trained psychotherapists, and that it utilized rituals and herbal remedies. Clients were urged to develop themselves spiritually; sessions were focused on the meaning of life and the individual's connection to God and to the cosmos. The clients' families often were called in, and advice was freely given. The Western-trained psychotherapists worked with the practical aspects of the case rather than the spiritual dimensions of a client's life.
Koss described a client who was seen both by mental health professionals and folk healers. When brought to the center, she was given medication for depression and visual hallucinations. The folk healers “exorcised” eight malevolent spirits. Despite the seriousness of the case at the outset, the client was discharged a week later and resumed her classes at secretarial school. The two types of practitioners had worked cooperatively, addressing themselves to various aspects of the client's belief system and behavior.
Koss was surprised to discover that the mental health professionals often sought out folk healers themselves for counseling. One psychologist consulted with a folk healer during divorce proceedings and was given instructions on how to contact his spirit guides to help him in court. With the help of the folk healers the psychologist worked through his problems in forming close relationships and eventually married again. He told Koss that the folk healing practices had been far more effective in his case than any psychotherapy he had previously received.
Koss (Koss-Chiono, 1992) later followed up clients who had received Western psychotherapeutic treatment in Puerto Rico and compared them with the clients of folk healers, finding that the latter group reported greater improvement. Clients who visited the folk healers (some 60% of all Puerto Ricans she questioned) also had higher expectations and this might have influenced the outcomes. Koss noted that folk healers did somewhat better than Western-trained psychotherapists on mood and behavioral complaints while psychotherapists were more successful with clients who had complained about disordered thinking.
Hallmarks of Effective Treatment
In his exhaustive study of cross-cultural practices, Torrey (1986) concluded that effective treatment inevitably contains one or more of four fundamental hallmarks:
1. A shared world view that makes the diagnosis or naming process possible;
2. Certain personal qualities of the practitioner that appear to facilitate the patient's recovery;
3. Positive patient expectations that assist recovery;
4. A sense of mastery that empowers the patient.
If a traditional medical system yields treatment outcomes that its society deems effective, it is worthy of consideration by Western allopathic biomedical investigators, especially those who are aware of the fact that allopathic biomedicine is the dominant health care paradigm for less than 20 percent of the world's population (Mahler, 1977). However, what is considered to be “effective” varies from society to society (Krippner, 2002).
It is also important to note that allopathic biomedicine places its emphasis upon “curing” (removing the symptoms of an ailment and restoring a patient to health), while traditional medicine focuses upon “healing” (attaining wholeness of body, mind, emotions, and/or spirit). Some patients might be incapable of being “cured” because their sickness is terminal. Yet those same patients could be “healed” mentally, emotionally, and/or spiritually as a result of the practitioner's encouragement to review their life, finding meaning in it, and becoming reconciled to death. Patients who have been “cured,” on the other hand, may be taught procedures that will prevent a relapse or recurrence of their symptoms. An emphasis upon prevention is a standard aspect of traditional medicine, and is becoming an important part of biomedicine as well (Krippner & Welch, 1992).
A differentiation can also be made between “disease” and “illness.” From either the biomedical or the ethnomedical point of view, one can conceptualize “disease” as a mechanical difficulty of the body resulting from injury or infection, or from an organism's imbalance with its environment. “Illness,” however, is a broader term implying dysfunctional behavior, mood disorders, or inappropriate thoughts and feelings. These behaviors, moods, thoughts, and feelings can accompany an injury, infection, or imbalance – or can exist without them. Thus, one may refer to a “diseased brain” rather than an “ill brain,” but of “mental illness” rather than of “mental disease.” Cassell (1979) goes so far as to claim that allopathic biomedicine treats disease but not illness; “physicians are trained to practice a technological medicine in which disease is their sole concern and in which technology is their only weapon” (p. 18).
Every human population, in every era, builds a specific worldview or “mythology” through its own culture. Specific views of the body, health, and sickness stem from this model of the world. Therefore, comparisons between allopathic biomedicine and indigenous ethnomedicine can be made utilizing these models. In the social and behavioral sciences, a “model” is an explicit or implicit explanatory structure that underlies a set of organized group behaviors. Their use in science attempts to improve understanding of the process they represent. Models have been constructed to describe human conflict, competition, and cooperation. Models have been proposed to illustrate such topics as the etiology of mental illness, the spread of disease, the interaction of personality dynamics and family interactions.
The U.S. National Institutes of Health Model
In April 1995, the Office of Alternative Medicine (OAM) of the United States National Institutes of Health held a conference on research methodology. The charge of this conference was to evaluate research needs in the field of complementary and alternative medicine ( CAM ), and several working groups were created to produce consensus statements on a variety of essential topics. The panel on definition and description accepted a dual charge: To establish a definition of the field of complementary and alternative medicine for purposes of identification and research; to identify factors critical to a thorough and unbiased description of CAM systems, one that would be applicable to both quantitative and qualitative research (O'Connor, 1995).
The panel proposed a definition of CAM . A "complimentary" healing system (e.g., massage) can be used as an adjunct to allopathic biomedicine while an "alternative" healing system is difficult to combine with allopathy because it is based on different assumptions about the cause and treatment of disease and illness (e.g., homeopathy):
Complementary and alternative medicine ( CAM ) is a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and well being. Boundaries within CAM and between the CAM domain and the domain of the dominant system are not always sharp or fixed. (O'Connor et al., 1997)
The second charge of the panel was to establish a list of parameters for obtaining thorough descriptions of CAM systems. The list was constructed on 14 categories first conceptualized by Hufford (1995):
1. Lexicon. What are the specialized terms in the system?
2. Taxonomy. What classes of health and sickness does the system recognize and address?
3. Epistemology. How was the body of knowledge derived?
4. Theories. What are the key mechanisms understood to be?
5. Goals for Interventions. What are the primary goals of the system?
6. Outcome Measures. What constitutes a successful intervention?
7. Social Organization. Who uses and who practices the system?
8. Specific Activities. What do the practitioners do? What do they use?
9. Responsibilities. What are the responsibilities of the practitioners, patients, families, and community members?
10. Scope. How extensive are the system's applications?
11. Analysis of Benefits and Barriers. What are the risks and costs of the system?
12. Views of Suffering and Death. How does the system view suffering and death?
13. Comparison and Interaction with Dominant System. What does this system provide that the dominant system does not provide? How does this system interact with the dominant system?
14. Evaluation. Are there data available that demonstrate the efficacy of the healing system? What research methods are appropriate for investigating the system?
For illustrative purposes, I will apply the National Institutes of Health Criteria number 13 to three traditional healing systems, asking two questions: What does this system provide that the dominant system does not provide? How does this system interact with the dominant system? I will use three examples: Balinese shamanism, Andean Kallawaya medicine, and Curanderismo folk healing.
Traditional Balinese Shamanism
On the island of Bali , Indonesia , there are many rituals and ceremonies that focus upon healing. In traditional Balinese practice, the name of the main temple ceremony is nyimpen and the dance of Calon Arang often is performed during nyimpen . The story of Calon Arang circles around an evil widow and her only daughter who were banned to the forest for allegedly practicing black magic. There are several variations of this story but all focus on her revenge against the people of the ancient Hindu Javanese kingdom of Daha after its Raja insults her by retracting an offer to marry her beautiful daughter. Calling up her demon legions, she transforms herself into a frightening figure with ponderous hanging breasts, bulging eyes, a long flamed tongue, and a mass of unruly flowing hair. Waving her magic cloth, she has become Rangda, the queen of the witches, and wreaks havoc with her powers. Understandably, this is one of the most powerful plays in sacred Balinese drama and its performance is always charged with energy.
When I saw this dance performed in 1985, the dancers seemed oblivious to the outside world as they enacted the great battle between the forces of the witch and those of humankind. It started with the lesser characters whom, when faced with defeat, called upon the aid of higher forces which transformed them into more powerful beings. Each of the succeeding transformations was met with mounting tension on the faces of the crowd and was supported by the growing crescendo of the gamelan orchestra. Children who were dozing suddenly woke up. The climax finally came when the Barong, a mythical creature who frequently comes to the aid of human beings, at last faces his arch-adversary, the malevolent witch Rangda, and the dancers shift from their usual sense of identity to become players in this cosmic drama.
Denny Thong (1993), a psychiatrist who organized the first mental hospital on Bali and who I interviewed during my visit to Bali in 1985, describes what occurred during a performance of this dance that he witnessed:
At that very moment, one of my staff was bringing to me another glass of the thick Balinese coffee that I had been using to keep from falling asleep at that late hour. Suddenly, without warning, he threw the glass over his shoulder, stood upright as if in anger, and quivered with wide open eyes. Abruptly he proceeded to turn and walk to a nearby papaya tree which he pulled out of the ground. That seems to have been some sort of signal because afterwards many others in the crowd, including a member of the orchestra, experienced the same radical transformation. My first frightening impression was that utter chaos had broken out. (p.79)
Overwhelmed by this sudden and unexpected turn of events, Thong sat confused and bewildered with no idea of where to look or what to do. Fortunately, the Balinese themselves had no such problem. Restraining the disorderly behavior of the more violent trance dancers, their attention focused once more on the stage and its surroundings. The players still were dancing, still in an altered state of consciousness, but one that was less intense. The gamelan played on but only with the mesmerizing continuous deep rhythm of the large gongs. Thong's most striking observation was that despite all the wailing and untamed antics, nobody was hurt. He recalled,
This led me to the conclusion that this was no true chaos; instead it was a wild but nonetheless orderly form of behavior. It was only at this point that I turned around to ask my Western companion, Christopher, a question about his feelings concerning this primal scene. The result was my second shock of the night when I saw Christopher sitting upright with the same dazed look in his eyes as the dancers. At that moment...all the trance dancers gathered before the Barong who began to lead a procession around the temple. Dear Christopher joined in as well. (pp. 79-80)
It took the efforts of a pemangku or village priest to gently bring Christopher and the other people back to their ordinary state of consciousness. With his assistants, and armed only with holy water, the pemangku wandered through the crowd sprinkling the entranced revelers; the sacred water quickly revived them. Could this phenomenon be categorized as "mass hypnosis"? Such a label would be less than accurate because there was no direct goal-orientation of the entranced individuals.
In Thong's (1993) opinion, the Balinese people's repressed emotions find an outlet in the dance and drama -- an outlet the culture has provided for them to abreact, either vicariously or directly. Classical dance and drama in Bali , based on legends and myths, are well attended and the more contemporary dramatic presentations are even more widely attended. In both the classical and contemporary performing arts one can encounter every possible Balinese emotion -- love, joy, anger, reverence. One can observe intrigue, sexual passion, jealousy, and the violation of all the cultural taboos. Not only do the players benefit from expressing these emotions and breaking the taboos, but the audience attains catharsis as well. From Thong's perspective, the other Balinese arts -- painting, sculpture, the creation of festival offerings -- help the Balinese to maintain a healthy frame of mind. They have retained their vitality; without them and the related cultural manifestations, uniqueness of Bali would have crumbled long ago.
In addition, I personally have seen balians (i.e., Balinese shamans) enter both transpersonal and other altered states during healing and exorcism ceremonies. The balian taksu is a healer with mediumship talent who alters consciousness to assist in the diagnosis of the ill and unfortunate. Sometimes, the diagnosis is bebai in which an evil spirit has been sent by a sorcerer. The victim's rival has paid the sorcerer to practice bebainan , or black magic, for purposes of revenge or jealousy. Thong concluded that in the "altruistic trance states”, a dancer responds to the needs of another person or a group of people. This state is usually reached during or after the performance of a ritual and, in Bali , would encompass all hypnotic-like phenomena during religious or healing ceremonies as practiced by the balian . The practitioners in this group rarely show signs of psychopathology. "Egoistic trance states”, on the other hand, are entered in response to an individual's personal needs. They are not preceded by a ritual and tend to occur spontaneously. In Bali , this state is believed to be brought about by the possession of an individual by a bebai or evil spirit. Members of this group usually have emotional problems that typically fall into the psychiatric category of "hysterical reaction”. In other words, Thong's altruistic trance state is likely to be transpersonal in nature while the egoistic trance state is not.
Shortly after my visit to Bali , Thong established a Family Ward as part of his psychiatric hospital. This involved organizing his 180-person staff into a traditional bajaar, the island's smallest unit of social organization. It is customary for members of a bajaar to work together toward a common goal. He took on the role of the klian banjar , or community leader and named several other assistants, using the traditional names and roles. A small temple was constructed, and the staff was told to identify the deity who would empower the temple. Some remarkable dreams and healings were attributed to Djero Gede, and a local balian confirmed that this powerful deity, indeed, had empowered the temple. The next step was to hold a piodalan , an annual festival, which was a great success replete with dances, shadow puppet plays, and traditional foods. Soon, families and friends of patients came to worship in the temple and attended the annual piodalan .
This experience led Thong to evaluate the mental health system he had help to construct in Bali . He realized that its adherence to Western methods and models “was often illogical and even absurd.” Hospitals in Bali included large halls with two rows of beds on either side, an arrangement the Balinese would consider “uninviting” and “terrifying,” since certain rules forbid them to sleep with their heads pointed in certain directions (p. 63). He noticed that some patients were frightened by curtains, which separated them from their families.
As a result, Thong initiated a Family Ward, which consisted of four compounds, each of which could house one patient and his or her family. In this way, the active participation of the family would be encouraged. The compounds were built of traditional materials, and each had its own entrance. During the day, patients would engage in ordinary activities, such as farming, carpentry, and similar enterprises. They could cook for themselves, using the kitchen and utensils that were supplied. The staff would spend a good part of the day discussing patient's problems, answering their questions, and listening to them express their feelings. The plan was to limit Family Ward admissions to first-time patients and to keep them for a maximum of two weeks. The rationale was that these patients were suffering from an acute psychotic reaction that would subside quickly, and then would be manageable on an out-patient basis. If there was no improvement, patients would be transferred to the regular ward. Patients and their families would be taught how to administer their own medication.
Both the patients and their families were allowed to utilize the services of balians and other traditional healers, if they so chose. One local balian was especially popular. He was a retired high school principal and his treatment consisted of pressing a number of points on the skin, beginning at the neck. With some, there was no reaction, while others writhed in pain. The balian concluded that these patients were the victims of bebian and administered the appropriate treatment. Thong remarked, “Astonishing enough…, several patients whom he treated showed remarkable improvement after his treatments” (Thong, 1993, p. 68).
At the end of one year, Thong and his staff evaluated the results of the Family Ward. Fourteen patients had been admitted, nine from Bali , and five from the surrounding islands. Of the former, eight recovered and one was sent to the Regular Ward; among the latter, four recovered and one was sent to the Regular Ward. Those who recovered were sent home, some for short periods of time as outpatients; none of them reappeared for additional treatment. Most of the patients were diagnosed with one form of schizophrenia or another, while one was suffering from depression, and another from drug addiction. The average amount of time spent in the Family Ward was forty days.
One patient was a 19-year-old girl with no schooling who had suffered an acute psychotic attack. She refused any food or drink unless it was given by a family member. She reported hearing voices of deities who ordered her to fulfill certain religious tasks. Her family shared her belief system and when she was admitted, seven of her brothers insisted on joining her. After sixteen days, and after the administration of anti-psychotic medication, she returned home with her brothers. Apparently, the voices had stopped and she decided to take an active role in her local temple. Thong (1993) wrote,
This case reminds me of the priest of Batur temple whom I described earlier. If we had admitted these patients into the main ward, thus branding them as mentally ill, it would have had dire consequences. The status of the individual would have suffered and the family would have endured a significant financial burden because they would have had to conduct special ceremonies to cleanse the patient of the spiritual pollution attributed to the main ward. (p. 69)
Soon, Thong's project aroused considerable controversy in the national capitol of Jakarta . The Indonesian Medical Association accused him of “dabbling with superstition and unscientific methods” (p. 68). At the end of 1987, Thong was ordered to close the Family Ward, and he was transferred to another island. In 1988, he arrived in Ujung Pandang , Sulawesi , where he continued to practice psychiatry and to write about his experience in Bali . I edited his story after it was translated by Bruce Carpenter. Our book, A Psychiatrist in Paradise, was published in 1993. However, it was never stocked by any book stores in Indonesia .
Andean Kallawaya Medicine
In 1996, I spent five days in La Paz , Bolivia , and vicinity interviewing practitioners of a unique form of ethnomedicine, the Andean Kallawaya system. I interviewed several Kallawaya practitioners including the president of the Sociedade Boliviano de Medicina Tradicional (i.e., the Bolivian Society of Traditional Medicine) and the president of the Associacion de Yatiris Tradicionales de La Paz (i.e., the La Paz Association of Traditional Spiritual Kallawaya Practitioners). The former group has thousands of members (about half of them women) while the latter is an affiliated group.
Kallawaya herbalists trace their tradition back to the legendary Tiahuanaco cultures of 400-1145 C.E., continuing through the eras of other pre-Inca cultures, the Inca Empire, and the Spanish conquest, to present times. Kallawaya healers are members of the Kallawaya ethnic group that speaks Aymara, Quechua, and/or Spanish; both the earlier Aymara and the later Quechua cultures had Kallawaya healers.
In ancient times, people saw no division between themselves and their environment. However, rivers and valleys created natural boundaries or ayllus , the ecological and cultural units of Kallawaya society. Kallawaya healers were once identified with certain ayllus, referred to as Qollahuaya , “places of the herbs.” The communities in the lower slopes (3,200 to 3,500 meters above sea level) grow barley, beans, corn (or maize), peas, and wheat. Those in the central communities cultivate oca (i.e., Oxalis crassicaulis ) and many varieties of potatoes on rotated fields that are 3,500 to 4,300 meters high. Those of the highland communities (4,300 to 5,000 meters) herd alpacas, llamas, and sheep. Traditionally, ayllu members from the three levels exchange produce and provide each other with the necessary foods to maintain a healthy and balanced subsistence.
Traditional Kallawaya follow three injunctions: ama swa , do not steal; ama llulla , do not lie; ama khella , do not be slothful. Kallawaya also believe in a principle of nature they refer to as the “boomerang law”: if you harm others, malevolent acts will return to you. Living by these precepts is felt to be fundamental in establishing and maintaining harmony within the community. A life of moderation, peace, and harmony is in accord with the Kallawaya maxims, and a dynamic equilibrium is needed to produce a healthy balance.
The goal of the Kallawaya medical model is to maintain and restore the harmonious relationship of community members, the community as a whole, and the natural environment. The Kallawaya practitioner needs to assure the availability of medicinal plants and proficient healers who are conversant with health, sickness, the natural realm, and the world of spirits. Prevention involves the practice of moderation in daily life, and the maintenance of trust among members of the community.
Kallawaya healers mediate between the ill person's body and the environment, attempting to restore the balance that has been lost. However, restoration of this balance is dependent on a number of factors--the sickness itself, its severity, and the cooperation of patients and their families. The confidence and the faith of the patient are key factors because herbal treatment is a slow process that requires a great deal of patience. Belief is felt to activate the self-regulatory mechanisms that are fundamental to recovery. In addition, considerable emphasis is placed on prevention; proper nutrition is seen as essential to the maintenance of health.
Kallawaya practitioners often travel to parts of Argentina , Chile , and Peru , but always in small groups rather than alone. Most Kallawaya practitioners are males, but talented females are admitted to the profession as well. If the patient can not go to the healer, the healer will go to the patient. However, female Kallawaya practitioners typically do not leave their homes, thus their patients must come to them.
In La Paz , there are clinics where patients can visit a Kallawaya practitioner. The function of these clinics is diagnosis and treatment regardless of its location. The patient's preference usually is home visitation, far from the influence of hostile spirits and unfamiliar surroundings and near to familiar animals, plants, and land. Western-style hospitals are dreaded, in part because the color white is associated with the death and burial of infants.
The personnel involved among the Kallawaya represent various skills and functions. Herbalarios collect plants; yerbateros prepare plants; curanderos apply the herbs and other medicines; yatiris (also known as amautas ) are spiritual healers; partidas are midwives. Over time, Kallawaya practitioners began to perform more than one function hence many of these traditional divisions have become less rigid. Nevertheless, all practitioners mediate between the environment and the patient and, in some cases, the community-at-large.
A common folk method of diagnosis utilizes a guinea pig. The procedure begins with tying the guinea pig to the patient's stomach or kidney area. A coca leaf preparation is placed over the head of the patient followed by a joint prayer affirming belief in the procedure. The guinea pig is removed and cut open so that its internal organs can be observed. Any anomaly of these internal organs is regarded as a representation of the patient's sickness. A small lesion in the animal's lung is most serious as it indicates a terminal condition on the part of the patient. This procedure did not originate with the Kallawaya, but still is used by some practitioners.
Another folk tradition that is taken seriously by some Kallawaya healers involves examining the patient's side for small scars that resemble puncture marks. These marks, in combination with certain behavioral symptoms, indicate an invasive condition, marked by high temperatures, brought on by sorcery or kharisiri . The marks indicate that malevolent spirits have entered the patients' body, usually near the liver, to steal their fatty tissue. These malevolent spirits can take the form of human beings referred to as karikari ; they live on fat and usually strike when their victims are not fully aware, such as when they are intoxicated (Bastien, 1992, p. 71). One practitioner told me that sorcery is quite rare and did not exist until the Spanish conquest; it is often related to the malignancy of the invaders.
Some practitioners use patients' dreams for diagnostic purposes because they represent the spirit communicating with the body. A voyage may be postponed due to negative signs in a dream. Nightmares may predict serious health problems. An important decision might be made on the basis of a positive dream. One person's dreams might even be an omen of things to come for the entire community.
The patient's behavior provides important clues for diagnosis and treatment. In general, a calm patient is healthy; crying and screaming may be signs of susto or “soul loss.” The symptoms of susto vary, but include depression, anxiety, laziness, loss of appetite, shaking, fever, nausea, hearing noises in the ears, and passing gas.
A practitioner's treatment is highly individualized but the importance of a balanced diet is generally emphasized. Practitioners advise their patients to “eat food from the area and during its season”; some fruits may be eaten before they are fully ripe for medicinal purposes.
The Kallawaya healers employ more than one thousand medicinal plants, about one third of which have demonstrated their effectiveness by allopathic biomedical standards, and another third of which have been judged “likely” to be effective (Bastien, 1992, p. 47). These plants are divided according to the three distinct “weathers” that Pachamama (Mother Earth) and Tataente (Father Sun) have given to their ayllu , namely hot, mild, and cold.
Coca plays a major role in many of the healing procedures because it is felt that the plant grows between the world of human beings and the world of the spirits. A coca and quinine mixture has been used to treat malaria--most notably, as Kallawaya healers tell the story, during the digging of the Panama Canal , a triumph that brought them to world-wide attention. The fungus of corn or bananas produces a substance similar to penicillin that is used for local infections. More serious infections are treated by a preparation similar to tetramycin yielded by fermented soil; this preparation is also used for ulcerated skin and chronic conditions.
Kallawaya medicine generally is accompanied by rituals involving prayers, amulets, and mesas --ceremonial fabrics on which objects are arranged, generally in a left-to-right manner, that symbolizes the journey from sickness to health. Llama fetuses are commonly used in the preparation of mesas because the llama is a sacred animal. Amulets are placed on the mesa or worn around the patient's neck, giving him or her confidence and spiritual power, especially when a patient complains of some type of deprivation. Different amulets represent health, love, wealth, or equilibrium with Pachamama and Tataente.
Mesas are often used to prevent sickness or imbalance, often for the entire community; when they represent offerings to the spirit world, they are burned after their utilization. The so-called Pachamama Mesa can be burned on any day of the week, often for a wedding or when crops are planted. The Mesa Gloria or Mesa Blanca is composed of 12 pieces of cotton on a white background and is burned on a Wednesday night in response to a thunderstorm. Sets of four figurines are placed on the mesa (e.g., four figures of horseshoes, houses, and llamas, four dice made of sugar, four pieces of St. Nicholas bread).
The Awicha Mesa or Chulpas Mesa is burned on Tuesdays or Fridays in honor of deceased members of the community to console their spirits and is related to the chulpas , the preparation of corpses for traditional funerals. However, it is believed that people who stroll through areas while funerals are being arranged sometimes fall sick.
One practitioner itemized the objects he uses for his mesas --coca leaves, religious figurines, “gold” or “silver” bread ( pan de oro or pan de plato ), alcohol, eggs, white flowers, wool, fat, and llama fetuses. If a llama fetus is not available, he may use a pig or sheep fetus.
Herbal preparations usually are ingested but occasionally are used in conjunction with a “steam box”; the naked patient enters a receptacle that has been filled with steam created from the medicinal mixture. The active ingredients of the herbs enter the pores of the patient at the same time as the sweat cleanses the toxins.
I observed a patient in one of these steam boxes in the Tambillo Hospital I visited on the outskirts of La Paz . In addition to the steam boxes and their cleansing therapy, the hospital was replete with hundreds of Kallawaya herbal preparations, all carefully prescribed, measured, and given to patients with explanatory procedures.
There is an armamentarium of procedures that do not involve herbs, for example, healing songs and dances. These songs are felt to be especially effective in treating insomnia. The dances are frequently utilized to renew the patient's supply of energy. Susto is treated in a number of ways; one practitioner mentioned asking Tataente “Am I allowed to heal this condition?” then burning incense, praying with the Christian rosary, and making offerings in the four directions of the compass.
The Kallawaya society attempts to maintain a balanced environment that exists in harmony with nature. Because prevention of sickness is an important element of the Kallawaya system, any disequilibrium deserves immediate attention. In rare cases, the community has the responsibility to expel members who endanger the balance. A more commonly assumed social responsibility is to support patients by bringing them food, money, music, and anything else that will maintain their faith and their motivation to recover; this community process is referred to as ayni . A festive ceremony for offering group assistance is referred to as a preste and is frequently used to treat susto . Ayni is especially important for people with chronic problems, because it demonstrates community support.
These practitioners are not shamans, even though several shamanic traditions exist in Bolivia . Shamans alter their consciousness to obtain power and knowledge to help and to heal their patients (Krippner & Welch, 1992), a practice absent from Kallawaya traditions. However, like shamans, Kallawaya practitioners maintain a wide scope of practice, applying their treatments to patients of all ages as well as to all types of sicknesses.
In the 1950s and 1960s, Bolivian pharmacists and physicians successfully curtailed the influence of Kallawaya practitioners by public humiliation, restrictive laws (and imprisonment for their violation), and denial of licenses (Bastien, 1992). Even though some Kallawaya practitioners incorporated various aspects of biomedicine into their procedures, physicians and politicians portrayed these healers, at best, as members of an antiquated tradition and, at worst, as charlatans. The success of Kallawaya treatment and the increasing surplus of allopathic physicians in Bolivia exacerbated the situation.
Mounting a counterattack, many Kallawaya healers stereotyped physicians as kharisris , mythic figures who steal fatty tissue, the source of force and energy in folk tradition. As a result, however, those Kallawaya practitioners who had adopted a few biomedical practices often lost patients.
In the 1980s, most Bolivian physicians and nurses discontinued efforts at integrating ethnomedicine because their superiors did not promote it (Bastien, 1992, p. 38). At the same time, there was a sharp resurgence in Kallawaya practice as the value of their medicinal plants was touted by biomedical research, and because Bolivian peasants could not afford biomedical treatments (in 1984 the cost of a penicillin injection was about $10.00 U.S. , several days wages for peasants).
In the 1990s, communication between physicians and herbalists in Bolivia improved because of the interest in ethnomedicine; the two groups collaborated on several conferences and even jointly staffed a few clinics. Walter Alvarez, a gynecologist and surgeon as well as a Kallawaya practitioner, was instrumental in helping the Kallawaya of one ayllu obtain a clinic staffed by both a physician and an herbalist. In summary, biomedical techniques are finding their way into Kallawaya practice without a loss of the tradition's unique identity.
Mexican-American Curanderismo
Frank and Frank (1991) contend that three main factors are present in an effective healing process: (1) the installation of hope through “naming” the problem and making the diagnosis in a context understandable by the client; (2) emotional arousal, dynamic healing techniques, and the creation of catharsis, hope, and confidence; (3) a feeling of control and a sense of mastery gained by the client in regard to the presenting problem. Because Mexican-American Curanderismo covers these three bases, it is not surprising that its survival seems assured. Nevertheless, formal investigations of the practitioners, their worldviews, and their technologies seem necessary before globalization, industrialization, and political opportunism erode the unique aspects of this singular system of healing.
Curanderismo, or Mexican-American folk healing, is a coherent, comprehensive system of healing that derives from the synthesis of Mayan and Aztec teachings with Mexico 's heritage of Spanish Catholicism. Traces of Arabic medicine and European witchcraft can be discerned as well. Its underlying concept is the spiritual focus of the healing; the typical curandera (female practitioner) and curandero (male practitioner) who subscribe to this worldview place the religious element at the center of their practice (Trotter & Chavira, 1981).
Diagnosis is made on the basis of the history of the ailment, the symptoms, and retrospectively by the response to treatment. Diagnosis may involve natural, psychological, and/or spiritual procedures. On the natural level, a practitioner can observe the patient and ask questions. On the psychological level, a curandera may claim that she can “see” her patient's “aura” or energy body; the size, color, and shape of this “aura” can be an important diagnostic sign.
On the spiritual level, a “spirit guide” often reveals the nature of a patient's problem in dreams. Initial diagnoses often are carried out by the patients themselves or by family members and neighbors. Etiology can also be natural, psychological, or spiritual. The role of bacteria and viruses is taken for granted as a possible causal factor. Another alleged natural cause of a patient's difficulty is empacho , indigestion due to a ball of food being lodged in the intestine or food sticking to the wall of the stomach. Psychological causes are felt to be behind bilis , a malady caused by anger or fear, envidia (caused by jealousy), mal aire (by imbalances in relationships or in personal qualities), and caida de mollera -- the perception that an infant's fontanel is too low due to his or her mother's neglect.
Spiritual etiologies abound; embrujada or sorcery involves the participation of demonic spirits while mal puesto results from a hex. Sometimes there is a combined etiology; empacho can be brought about when a mother forces her child to eat too much or to consume food that the child dislikes.
The patient's behavior is used to help make a diagnosis; for example, if diarrhea, crying, vomiting, and sunken eyes accompany a fallen fontanel, the diagnosis of caida de mollera is confirmed. One form of envidia is mal ojo , which occurs when someone with an “evil eye” stares at the victim because of envy or desire. Symptoms include fever, headaches, vomiting, and drooping eyes. On the other hand, gas, constipation, a bitter taste in the mouth, and a “dirty white tongue” accompany bilis .
Specialists generally carry out treatment. Herbal treatments are supervised by the herbolaria , medica , and herbalista while the señora prescribes home remedies. The patient's “vibrating energy” may need to be modified by incantations or manipulation. Suggestion, confession, and persuasion are employed; the practitioner may increase patients' self-esteem by getting them involved in group activities and church functions, or asking them to visit a holy shrine. The magica combines herbs with such spiritual practices as prayers, chants, sprinkling holy water, burning incense, and lighting candles. Exorcisms are performed by an espiritista who is adept at enlisting the help of benevolent spirits and ridding the patient of malevolent ones. The etiology must be accurately made in order to insure the proper type of treatment, as well as to select the most appropriate practitioner.
There are important regional differences in Curanderismo. For example, its model of health emphasizes “balance” in relationships and behavior. But a “balance” of emotional “humors” and the avoidance of an excess of either “hot” or “cold” foods is important as well. An exception is found in southern Texas where “hot” and “cold” humoral treatment is virtually absent. The role thought to be played by witchcraft in a malady also varies from location to location.
Prognosis is favorable if the treatment regimen is closely followed. However, failure to comply may lead to a worsening of the condition or, in the case of such problems as caida de mollera and mal puesto , to premature death. Suicide can be the result of metaphysical sources or as a failure to find a spiritual approach to life's problems.
The practitioners will vary depending on location; a practitioner who is referred to as a curandera in San Diego, California, may correspond to a señora in San Antonio, Texas, a medica in Santa Fe, New Mexico, and a parchera in parts of Guatemala. Most practitioners of Curanderismo are women, but the proportion varies geographically. Curanderas typically are “called” to their profession by spiritual entities; they apprentice themselves to a friend or relative until they are considered ready to practice. Most of them are part-time practitioners who do not charge a specific fee but are given a small offering or gift. The setting is often the home of the practitioner and its function is both diagnosis and treatment.
The goal of the Curanderismo model is to assist the recovery of the patient, restoring his or her “balance” within a social framework that preserves the traditions of the family and the Mexican-American subculture. Suffering and infirmity are seen as an inevitable part of life, and as part of God's plan to instruct human beings and lead them to salvation. Sickness is not seen as a punishment from God but as a challenge.
Hockmeyer (1990) investigated a specific curandera, Diana Velasquez, who had a staff position in a Denver community health center. Velasquez' success was attributed to her use of holistic, spiritual, ritualistic healing practices; to her charisma, gender, and ethnicity; to her ability to serve as a model of bicultural adaptation; and to a worldview that she and her clients shared. Velasquez report that she only had to make minor adaptations in practicing Curanderismo to fit the bureaucratic requirements of the state mental health system.
The cases dealt with by Velasquez were far from simple, ranging from a young woman who had been continually sexually molested by her grandfather to a man undergoing a personal identity crisis when his wife found a well-paying job. She also had to cope with accusations by young “acculturated” members of the Mexican-American community that she was “nothing but a witch.” Velasquez' diagnostic categories resemble those found in the U.S. Southwest, including brujo and embrujada, both of which she treated with rituals to re-establish “balance.” She even successfully treated a Western-trained psychotherapist who was suffering from visual hallucinations during the day and insomnia at night, relying on her customary rituals.
Ethnomedicine and Biomedicine
The World Health Organization (Mahler, 1977) has defined health as “a complete state of physical, mental, and social well-being, not merely an absence of disease or infirmity” (p. 3). The value of ethnomedical practitioners and their incorporation into biomedical systems has become widely heralded since their advocacy by the World Health Organization, but the high cost of training folk healers, the reluctance of the medical bureaucracy to accept them, and the decline of ethnomedicine in many parts of the world have discouraged such incorporation. The objective of available medical care for all people of the earth by the beginning of the 21st century depends upon granting folk healers professional autonomy as well as to educate them in abandoning worthless (and sometimes harmful) practices, and to teach them and their communities about effective public health measures (Bastien, 1992, p.27). Many ethnomedical practitioners use adaptive strategies that represent living and dynamic systems, subject to change in response to the community and the environment.
However, it is important not to romanticize folk healers and ethnomedicine. Lead content is very high in some traditional medicines, including those used by certain ethnic groups in the United States . For example, a 1-year-old boy was diagnosed with brain damage by a traditional Tibetan practitioner. The practitioner gave the boy a Tibetan remedy and told him to take it three times per day. After four years, the boy was diagnosed with neonatal asphyxia, and the cause was determined to be the Tibetan remedy, one which had a high lead content (Moore & Adler, 2000).
Ayurvedic medicine, a traditional medicine widely used in India and in some parts of the United States , is usually made of vegetable products, but sometimes of metals and minerals as well. The latter may include lead, mercury, and arsenic, all of which can be toxic if taken over a period of time (Saper et al., 2004).
In some Mexican communities, two remedies known as “Azarim” and “Grota” are commonly prescribed by folk healers for empacho (intestinal sickness). “Litargio” is also prescribed as a deodorant.
All three have an extremely high lead content and are harmful even if used for short time periods (Smolinske, 2005).
Physicians who treat diverse ethnic populations need to become aware of traditional medicines often used in these communities. In addition, there is an increasing use by the general U.S. population of folk remedies as alternatives or enhancements to allopathic medical prescriptions. Physicians need to inquire about their use, and to be knowledgeable about both the benefits and the risks.
At the same time, if a Balinese shaman, a Kallawaya healer, or a Mexican-American curandera can not help a patient, there may need to be a referral to an allopathic physician, especially if surgery is needed; in La Paz we were told it was a common practice for referrals to go in both directions as some physicians would send patients to Kallawaya healers.
Most people who use these three systems, as well as comparable systems in other parts of the developing world, recognize the advantages of biomedicine. Yet they are often aware of how biomedicine can be used as a political instrument to discriminate against ethnic groups and socioeconomic classes, and to create dependency relations with the industrialized countries who supply (and profit from) allopathic medicines and implements. In this way, the contrast of ethnomedicine with that of allopathic biomedicine enters what has been called the postmodern dialogue. From a postmodern perspective, “official” medicine (i.e., biomedicine) can be contrasted with “traditional” medicine (i.e., ethnomedicine), observing that the latter has had to struggle for legitimacy against powerful forces.
Ethnomedical practitioners, according to my informants, attempt to preserve their own way of thinking with its emphasis on living in concord with the natural environment, on balance and harmony, and on community support and spiritual direction. Such concepts generally are foreign to allopathic biomedicine (Hufford, 1995).
Biomedical technology often determines what is to be taken as authoritative knowledge and, in turn, establishes a particular domain of power. Biomedicine typically extends this privileged position to economics, politics, and class relationships. Legislation, medical schools, licensing, and medicinal terminology all interact to jealously guard the power of biomedicine. It is no wonder that ordinary people frequently view biomedicine as serving powerful groups in their country while they struggle for a vestige of power over their own lives (Bastien, 1992, p. 17).
The celebrated ethnologist Claude Leví-Strauss (1955) proposed that the kind of logic developed by indigenous people is as rigorous and complete as that of modern science. It is not the quality of the intellectual process that differs but the mode of expression and application. For example, the cultural myths of pre-Columbian Mexican and Central American societies not only were comprehensive guides to daily conduct but also provided an explanation for the mysteries of the universe. Each mythic episode can be interpreted in several ways according to the context and the listener's understanding. The symbols used are manipulated with such economy that each serves a wide range of philosophical and religious ideas. Quetzalcoatl was the “feathered serpent” who symbolized the transformation of matter into spirit, as well as the god of the winds, the Lord of Dawn, the spirit of the sacred ocelot (a fierce jungle cat), the last king of the Toltecs, and (following the Spanish conquest) Jesus Christ.
These three ethnomedical models of healing emphasize spiritual aspects of health and sickness, a dimension long ignored by biomedicine. I use the term “spiritual” to describe those aspects of human behavior and experience that reflect an alleged transcendent intelligence or process that inspires devotion and directs behavior. The spiritual dimension of life is evident to any person who becomes aware of a life meaning that extends beyond the immediacy of everyday expediency and concerns. The difference between religion and spirituality and can be described as a distinction between adherence to the beliefs and practices of an organized religious institution and a person's relationship to an alleged transcendent reality either with or without regard to a formal religion or creed (Krippner, 2002).
There are now dozens of studies dealing with “spiritual health” in the English language literature (Krippner, 2002). Four major dimensions have been studied in these investigations: meaning and purpose in life, intrinsic values, transcendent beliefs and experiences, and community relationships. Some of the studies found lower levels of depression among individuals who manifested one or more of these four dimensions.
In several studies of African-Americans, high rates of hypertension were observed; the social support given by churches and communities have been suggested as antidotes to this condition (Krippner, 2002, p. 195). The link between physical health and spirituality or attendance at religious services has been affirmed in several investigations; it is especially apparent in reduced hospital stays, lower blood pressure, fewer heart attacks, reduced stress levels, and enhanced immune functions. However, there are exceptions to these generalizations. Some people feel abandoned by God when they become sick; others refuse to take their children to a medical practitioner for fear of contravening “God's will.”
There are ecopsychologists who believe that healing the planet is basically a shamanic journey; if so, traditional medical systems can play a vital role in this endeavor. But while herbal medicines, indigenous treatments, and shamanism are becoming faddish in the West, indigenous systems are becoming increasingly endangered. It is crucial to learn what shamanism and related systems of healing have to offer the postmodern world before archival research in libraries replaces field research as the best available method for investigating these healing systems. Their longevity indicates that they have served many groups of people quite well over the millennia. The question remains as to what they can offer a world where allopathic biomedicine is not only revered but also powerful.
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The preparation of this paper was supported by the Chair for the Study of Consciousness, Saybrook Graduate School and Research Center , San Francisco , California , U.S.A. It was given as the keynote address at the World Congress of Ethnomedicine, Munich , Germany , 8-10 October 2005.