health, culture. medicine and medical systems are not based on any one model or paradigm, and it is this very reason that renders understanding among spe-'.
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HEALTH AND TRADITIONAL MEDICINE CULTURES IN LATIN AMERICA AND THE CARIBBEAN* DUNCAN PEDERSENand VERONICA BARUFFATI Box 2117, Lima
100, Peru
Abstract-In this article, the authors summarise the origins and development of traditional medicine cultures in the Latin American and Caribbean regions, beginning with an overview of terminology and definitions related to ‘medicine’ and ‘medical systems’. A short look is taken at original medicine cultures and at how they syncretised with colonial European medicine to give birth to a mosaic of lay and traditional medicine practices still in evidence in the New World today. A review is then made of the latest and main bibliographic sources in traditional medicine for the region, which are then analysed briefly. The mam body of the paper deals with the different research approaches to traditional medicine cultures of which seven are discussed here. The authors conclude by stressing the need for closing the gap between the social and medical sciences in order to reach a better understanding of the health needs of the population. Biology and culture are at the centre of the discussion between medicine and anthropology where two trends dominate, viz. the socio-cultural and the biomedical models. The main task for ethnomedical researchers in the Latin American region is to work towards the creation of a bio-sociocultural model in an attempt to enrich systems qualitatively in the development of more humane and efficient interventions. both in the clinical field as in the field of health policies and strategies.
makes a very complete and revealing review of Anglosaxon literature on the subject [4] and winds up asking himself whether it is really necessary to differentiate between ‘medicine’ and ‘medical systems’. It seems that such a distinction is necessary and useful, at least according to the definitions put forward by Landy [S] who states that ‘medicine’ is a cultural manifestation of health-related phenomena, such as concepts, norms, values, practices and materials, whereas ‘medical systems’ are more of a social manifestation, more related to structure and organisation. The concept of a medical system, or health system as others prefer to call it, was created in recent historical times by countries as a result of the division of labour, and includes, in its narrow meaning, a more or less complex bureaucratic apparatus of schools, hospitals, clinics, professional associations, companies and standardisation agencies who train personnel and maintain an infrastructure for biomedical research and services of varying degrees of complexity for the prevention, curing, care and rehabilitation of the sick. From this unilateral and restricted perspective, all other forms of health care and services which are not part of the official, legally sanctioned structure, are generally ignored and looked down upon as marginal curiosities of medicine or mere charlatanry and superstition [6]. Today, the situation is different, and medical systems-according to Leslie-ought to be considered as pluralist structures in which cosmopolitan or modern medicine is but a component, on a par with other therapeutic alternatives [6], many of which are part of traditional medicine cultures. In the wider sense. therefore, we should recognise that the TMCs form part of original cultures and that they embrace the whole gamut of socially defined concepts, values and behaviour which are consciously adopted to alter or restore health and which, on the whole, attempt to restore the balance between man and his natural and social environment.
At a first glance. we can say that Traditional Medicine Cultures (TMC) are ways of experiencing, interpreting and managing the health and disease situation, integrated by certain concepts and values of society. Young, in his approach, offers a more strict and operational definition of ‘Medical Traditions’ when he states that they are different combinations of medical knowledge. practices, skilled personnel, apparatus and materia medica [l]. These different approaches to TMC may, of course, be questioned from various angles, but a start must be made somewhere in an area where the absence of the most basic heuristic concepts and ideas appears to be the norm [2-41. In fact, the concepts of health, culture. medicine and medical systems are not based on any one model or paradigm, and it is this very reason that renders understanding among spe-’ cialists in public health. clinical medicine and medical anthropology difficult. This is but another aspect of the rift which exists between the natural and social sciences. Although the adjective ‘traditional’, when used to describe medicine. has been sanctioned by use. it remains unsatisfactory because of its connotations. and equivalent terminology found in the literature. such as ‘indigenous’. ‘popular’, ‘folk’, ‘primitive’. ‘non-professional’. ‘pre-scientific’, ‘lay’, ‘non-Western’. ‘aboriginal’ has not been agreed upon. either in academic circles or by the very users of these practices. On the other hand. the concepts of ‘medicine’ and ‘medical systems’ have been dealt with in various ways-often contradictory-by different authors. Press. in an attempt to clarify this terminology,
*This article is based on a document presented at the Work Group on Health and Traditional Medicine Cultures in Latm America and the Caribbean. organised by the Panamerican Health Organisation*World Health Organisation in Washington DC. 1983. 5
DUNCAN PEDERSENand VERONICA BARUFFATI
6
Thus said, and putting aside the need for a better definition of these concepts, let us now deal with the field of health and TMC in Latin America and the Caribbean. BRIEF HISTORICAL
OUTLINE
As in all human societies, different ways of experiencing, interpreting and managing the health and disease situation existed in the New World. Although paleobotany and paleopathology, archeology and ethnohistory have casted some light on a horizon still submerged in the darkness of the past, findings are still too fragmentary to be able to reconstruct the prehistory of disease and medicine of the peoples in this region of the world. At the beginning of the 16th century, Indoamerican medical cultures came into contact with other medical traditions introduced by the Conquest and subsequently by the colony within a dominant sociopolitical framework. In an area of great cultural diversity, such as the Caribbean and Central America, the Mesoamerican medical traditions fused with other medical forms and cultures introduced throughout the Conquest and European colonial expansion, in a process of complex hybridisation of medical knowledge submerged in the religious syncretism of pre-Hispanic gods and Christian saints. The complex spiritual and religious cosmology of certain Caribbean islands and of the region which today includes Haiti, Surinam and coastal areas of north-eastern Brazil are intricate manifestations of Indoamerican, African and European traditions. In the Andean realm, in the tropical rainforest areas of the Amazonian Hylea, in the valleys and highland plateaux of the Andes and in the lowlands of the Pacific coast, original medical traditions developed, influenced by great ecological diversity and in close relation with the dominant cultural horizons with very advanced political and religious systems. In Precolombian times, these horizons expanded to occupy considerable parts of western South America, maintaining active influence on the most southern parts of the continent. So much so, that even today there are homologous. terms and concepts in the denomination and explanatory model of diseases in very distant regions of the American continent. The arrival of the Spaniards in the Andes resulted in a syncretism of Iberian, Greek and Precolombian medical traditions which produced a medicine and a pluralist medical system which was represented throughout the colonial period by phlebotomists, barbers, embalmers or bonesetters, herbalists, midwives, healers, sorcerers, druggists and religious doctors [7]. On the Atlantic side of the South American continent, among the human settlements of the Amazon basin and in the cities and towns of the Brazilian coast, similar phenomena occurred, but with certain different characteristics. At the end of the 19th century, the Portuguese nobility introduced the Spiritualism of Kardec which superimposed on the various forms of popular Catholicism, resulting in present day Umbanda and other religious traditions such as Candomble, Macumba and Xango, all of which maintain a great variety of specialists in the art of curing, e.g. healers, chanters and macumbeiros with
their own sanctuaries and pilgrimages to shrines where complex therapies are combined with medicinal plants, massages, prayers. rituals and surgical interventions carried out in states of spiritual possession and trance. Independence and the appearance of new republics throughout the continent continued the hybridisation process of medical traditions, and the introduction of new forms of economic dependence had their equivalent in culture and technology. The natural sciences devoted themselves successfully to local medical traditions and crafts which made way for he birth of modern medicine. Since then, the medicine which today we call modern, Western or cosmopolitan and scientific began to establish itself alongside these transactional processes of medical traditions. and started to incorporate and appropriate medicinal plants, herbs and some of the main assets of Indoamerican taxonomy into its own therapeutic arsenal. The expansion of modern medicine in the region began in theurban concentrations of the colonial and republican era where the Protomedicatos and university schools of medicine were set up. Religious missions were equally important in the introduction of Western medical practices, not only by installing the first hospitals in the cities, but also by taking modern medical services to the most remote indigenous settlements throughout the continent. During the 20th century, a particularly strong movement began to introduce human and technological resources of modern medicine to all levels, on the grounds that these were the only adequate response to the health needs of the population. In Western medical and pharmaceutical industry there is a strong tendency to support the introduction of a model of health services which disregards traditional medicine cultures in the attempt to achieve total health coverage, while at the same time creating a market and generating greater demand for drugs, medicines and high cost technologies. In the long run, however, these have proved to have a limited social impact and an inadequate capacity to respond to the health needs of the majority of the population [8]. In short, in the cities, towns and rural areas of present day Latin America and the Caribbean, we are faced with a mosaic of intermediate models, a consequence of the historical relations between Indoamerican medical cultures and the medical cultures of other continents, resulting in complex medical systems which are an organisational response to the cultural forms of medicine continuously recreated by society in its struggle against disease and its permanent quest for health. The Latin American and the Caribbean region is particularly rich in its medical traditions and systems which, far from being an undesirable vestige of a remote past, are a contemporary, dynamic and ever changing cultural expression, part of the survival strategies resulting from acculturation processes, and social, political and economic crisis rampant in the region. A LOOK AT THE MAIN BIBLIOGRAPHIC SOURCES FOR THE REGION
Faced with these cultural processes and social strategies, let us now quickly revise the bibliography
Health and traditional medicine cultures of this region of the world of the last few decades. This revision does not claim to be exhaustive, but hopefully it will give us a more diachronic and historical perspective of the evolution of written works on TMCs in the Latin American and Caribbean region, with the aim of seeing who has dealt with this subject. and what the recognisable motivations and tendencies are, in the task of salvaging popular knowledge and that of contemporary traditional medicine practices and cultures, We are going to restrict ourselves even more in this revision by looking at bibliographic sources which have appeared in the last decade [9] in special reference to Latin America and the Caribbean region with the exclusion of the Indexes and Abstracts of specialised collections, anthologies, medical ethnographies, monographic series, magazines and newspapers of mainly North American (and European) authors which have mushroomed over the last ten years and which include-amongst their varied titles-various aspects of medical anthropology, some of which refer to countries or regions of Latin America [IO]. Thus, in 1976, the first annotated bibliography on Africa, Latin America and the Caribbean appeared under the title of Traditional Medicine: Implications ,for Ethnomedicine, Maternal and Child Health, Men tal Health and Public Health by Ira Harrison and Sheila Cosminsky [I I]. This bibliography is a collection of the most outstanding literature in the field of traditional medicine published between 1950 and 1975 [l2]. The section on Latin America and the Caribbean was compiled by Cosminsky and includes 506 titles divided into 7 sections from mainly Anglosaxon sources, although there are also references in Spanish for Latin America. In 1978, three important bibliographies were published for the Region. The first is entitled Bibliografia Seleccionada en Antropologia Medica para 10s Pro.fesionales de la Salud en las Americas, edited by the Field Office/Mexico-U.S.A. border of PAHOjWHO [l3]. This bibliography is oriented towards health professionals and administrators, and excludes historical. theoretical and descriptive works. The list of references comprises a total of 897 titles divided into a general section and country or region sections. The region of the Caribbean Islands has 65 titles, Central America 23 I, North America (including two sections on U.S. Indians and the Mexican Americans) 239 titles, and finally South America with 251 references. .Although the distribution of the number of titles per region seems to be well-balanced, most of the authors are from the United States and publications are largely edited in English, a few in Spanish and Portuguese and fmally some in French. A second series of bibliographic references on TMCs was published in May 1978 by BIREME/PAHO Regional Library of Medicine. in the Serie Bibliograjica No. 3: Merlicinu Tradicionul [ 141. The references are in alphabetical order and bring together 337 titles, mostly by Latin American authors (in Spanish and Portuguese). and although it is made clear that the articles. documents and monographs listed are not available in the BIREME library. the bibliography has the advantage of including Latin American sources (mostly betw-een 1930 and 1976) which are not usually found in other available bibliographies. The third
bibliography published in 1978 is the Bibliogruf’u comentadu de la Medicine Trudicionol Mesicunu (190@1978) by Axel Ramirez, published by IMEPLAN [15]. It contains 500 titles of textbooks, articles and leaflets with a brief commentary, and it is considered the most complete bibliography available on traditional medicine in Mexico this century. In I98 I. the Bibliogrqfiu Lutinoumericunu some Ciencias Sociales Aplicadus u Sulud appeared. by R. F. Badgley, G. Bravo, C. Gamboa and J. C. Garcia, edited by PAHOjWHO [16]. This bibliographic series is the only one of its kind in that it compiles not only works which have appeared in magazines and formal publications on the subjects, but also those works which have appeared in ‘informal’ sources, manuscripts or mimeograph, or in magazines with a very low circulation, by mainly Latin American authors. The bibliography includes 1674 titles and is considered by the authors as a representative-not exhaustive-sample of the volume, quality and basic trends in Latin America of research carried out in the field of social science and health for the period 195k-1979. The first section includes 448 titles under the heading Medicina Tradicionul, and comprises all those works related to ‘native medical systems’ (healers, therapies, beliefs, etc.) and their relationship with Western or modern medicine. The other sections include various articles related to the subject although they have been included under other subtitles in the bibliography. This is without a doubt the most complete bibliography of Latin American authors in the field of traditional medical cultures published to date. Since then, no bibliography related to TMC and health for the Region of Latin America and the Caribbean has been produced, except for one of 750 titles elaborated by GIRAME (Groupe Interuniversitaire de Recherche en Anthropologie Meditale et en Ethnopsychiatrie) in Canada and published Sante, Culture, Health: Bulletin recently in d’information en Anthropologie Medicale et en Psvchiatrie Transculturelle [l7], which is to be updated and completed for a future edition. Just as we were finishing this article, we received a copy of Antropologia MPdica y Medicinu Traditional en Colombia compiled by Xochitl Herrera and Miguel Lobo-Guerrero and published in Bogota in 1982 by the Centro Cultural Jorge Eliecer GaitPn. This annotated bibliography contains 71 titles divided under the following headings: General studies, popular medicine and indigenous medicine.
THE MAIN TRENDS OF STUDIES RELATED TO TMC IN LATIN AMERlCA AND THE CARIBBEAN
From an analysis of the annotated bibliography of TM in Latin America and the Caribbean by Harrison and Cosminsky and of the section related to TM in the Latin American BibliographJl of Social Sciences Applied to Health of PAHO/WHO, we can make the following statements: (a) Most authors are from the United States of America. The number of Latin American authors comes to almost half the total mentioned. most being
8
DUNCAN PEDERSENand
Mexican and Peruvian. Other countries are represented by l-5 authors. (b) The areas and countries studied present a very asymmetrical picture. Mexico and the so-called Mexican-Americans are the subject of a third of the works listed in the two bibliographies. Peru comes next with llrl5’~ of the references, followed by Colombia and Guatemala. The other countries, notably Brazil and the Caribbean area, constitute a very insignificant part of the listed titles. (c) The subjects covered in the works listed in the bibliographies are varied, but there is an obvious lack of methodological or theoretical works except for a few general descriptive ones referring to the Latin American region as a whole. (d) The material difficulties in publishing and gaining access to this information in the Latin American and the Caribbean region are enormous. In fact, many of the bibliographic references to Latin American authors are very minor editions whose circulation is limited to a few individuals or research and teaching centres. The governmental sector practically ignores this material, even if produced in its own country, with the result that the structure and behaviour of TM practices is hardly known. For this reason it rarely appears in health policies and in the drawing up of the legal and administrative structure of this sector, nor in medical systems and service programmes. Let us now take a look at the main approaches and trends in the two annotated bibliographies in an attempt to establish the predominant interests and motivations thereof, and to point out the apparent shortcomings in the references and bibliographic material in the field of TM for this region. The botanical-pharmacological
approach
Studies related to medicinal plants form the largest category [ 181 in both bibliographic series, constituting about a third of the total references. It is worth pointing out that in this category, authors show a special interest for hallucinogenic plants and psychotropic substances in general. Most of the studies are related to the species Banisteriopsis, dealing with its ethnography, history and contemporary use. Less attention has been paid to coca and the Lophophora and Trichocerius species, and only in relation to Mexico and Peru. There are various references to medicinal plants and their uses, botanical names and their active pharmacological properties. Many works are simply descriptive with a positivist and extractive handling of data. Since colonial times there has been interest in discovering plants with their own therapeutic properties, some of which are found in today’s pharmacopoeia. This empirical search was succeeded-with the advent of modern chemistry and pharmacologyby an interest in isolating the main ‘active’ properties of the plants. This is still in evidence today, with the backing of large drug manufacturers and pharmaceutical producers. Although the botanical, pharmacological approach to TMC is necessary in some cases. it remains a unilateral and fragmentary way of identifying the medicine and medical systems of Latin American peoples. We cannot separate plants and
VERONICA BARUFFATI
their therapeutic uses from popular knowledge of disease and its causality system, nor from the social context of the therapeutic act. much less so from the properties the users and healers ascribe to them. Although the botanical-pharmacological approach has contributed obvious benefits in the treatment and management of certain diseases and symptoms, we should try to avoid isolating experiences to the laboratory out of the cultural and ethnographic context which dominates the sick person-healerhealed person interaction. Moreover, a strictly biochemical appi Jach while expanding the modern pharmacopoeia with medicinal plants of ‘verifiable’ pharmacological properties, leads to the undermining of traditional medicine practices and the subsequent enrichment of the pharmaceutical industry and trade, which puts back on the market a more elaborate product at greater cost to the consumer. The promotion and sale of new pharmaceutical products not only represents a new risk for the health of the population because of potential iatrogenic effects, but also a substantial drainage of funds from the importing countries who will have less money to spend on health activities, given that a growing percentage of the meagre public health budgets in the Latin American and Caribbean region are earmarked for the purchase of modern drugs and medicines [19]. Although there has been an increase in the inscription of patents and consumption of ‘biomedicines’ (prepared with medicinal plants and natural products), investment in this area is still marginal compared to the huge interests involved in patents and the production of chemical pharmaceutical drugs which is in the hands of a few commercial giants in France, Switzerland, Italy, Japan, Federal Republic of Germany and the U.S.A., which in 1970 produced about 80% of medicines produced world wide [20]. The botanical and pharmacological ‘approach to the study of TMC and medicinal plants should take distance from the extractive and utilitarian approach and adopt a more integrating position in the reappraisal of traditional medicine, protecting and defending it from the interests of the pharmaceutical industry. ‘Folk’ The scientiJicism
approach
and
the
application
of
The second most important trend in both bibliographic series is represented by studies of ‘folk’ medicine and the application of ‘scientificism’ to traditional medicine. The 50s and 60s were characterised by studies of ‘folk’ medicine which were mainly descriptions of traditional medicine beliefs and practices. In general, TM is considered as a historical vestige, often referred to as pre-scientific, and therefore belonging to the field of ‘non-sciences’ with connotations of inferiority compared to modern scientific medicine. On the whole, these descriptions of medicine as part of ‘folklore’ are made from an etic viewpoint, from outside the actual TMCs. Observers look in from outside with their own predetermined categories, regardless of whether they are valid for the culture they are studying. For this reason, the ‘folk’ approach is often characterised by a Western, natu-
Health
and traditional
ralist view of disease and treatments, not often shared by the societies under study. Both physicians and anthropologists who have been attracted by manifestations of TMCs frequently compare their ethnographic notes with the classification categories of Western medicine and medical systems. In this way, equivalents in traditional medicine and Western nosographies were sought, in an attempt to interpret the entities of each culture (e.g. ma/ de ojo, ma/ aire, susto or espanto) as equivalent to clinical nosological entities of a biological and psychological nature of Western medicine. It is evident that this folk approach has not made any significant contribution to the study or change of the Latin American reality in this field. This is not perhaps because of the researchers, but rather because of the ethnographic method which must be improved in order to be able to exact precise cultural descriptions for comparison purposes [21]. In addition to this need for a new ethnography for the advancement of cultural anthropology, it has been recognised recently that there is a need to develop ethnomedicine as a science which studies how the members of different cultures think about health and disease and how they organise themselves socially in the management and treatment of disease [22]. The branches of scientificism which have dealt with TM do so from a “positivist view of a universal, empirical, atemporal science, free of values” [23]. Positivism agrees with the concepts of sociological functionalism which is why some authors in the 70s sought the social functions of disease and healers. But these interpretations mar the structural character of the relation between health, disease and society, tending to deny the existence of any scientific laws related to the very essence of phenomena, restricting itself to the “mere level of relations between phenomena” [23]. The cultural anthropological symbolism
approach: shamanism
and
This is the third trend amongst researchers of TM where studies related to shamanism and symbolism predominate. Most of the works which come under the heading of cultural anthropology in recent decades are rich ethnographic descriptions whose contribution to clinical and preventive medicine is-at present-of marginal and limited relevance because of its phenomenological nature. The orthodox cultural approach tends to go no further than inter-relating the parts which make up the whole of TMCs, attributing them a coherent, ideal and logical order, without apparent contradictions. The few cultural anthropologists who have worked in this vein in Latin America and the Caribbean seem to have attempted, a systematic study of the mystical. symbolical and cosmological dimensions of traditional medicine to the point of constructing a model which is the antithesis of the conventional biomedical interpretation of health and disease. Some of the works related to shamanism and symbolism in Latin America have been influenced by the structuralist approach of Levi-Strauss who insisted on the integration of individual perceptions, collective meanings and social behaviour. giving priority to the study of
medicine
9
cultures
symbols in an attempt at reaching a better understanding of these behaviours [24,25]. Although the studies related to shamanism have contributed to the creation of an awareness of these practices in the Mesoamerican, Amazonian and Andean regions, researchers have tended to concentrate on shamans or great healers with a regional influence, or on atypical cases of shamanism. Little attention has been paid to other types of healers and their practices which is why very little is known about the typology of shamans, healers, TBAs and other specialists in Latin America. There have been very few studies which have tried to make an objective analysis of the results of shamanistic therapies and other procedures in people who have resorted to these practices. Finally, studies related to shamanism and endorphins, recently published in Canada by Raymond Prince of the University of McGill [26] are opening up perspectives for neuropsychiatric and pharmacological research in this area, representing a new field of research in psycho-anthropology. as yet little known in Latin America and the Caribbean. The historical
approach: ethnohistory
and archeology
Research which has approached TMCs in Latin America and the Caribbean region from ethnohistoric sources and archeological findings form an important part of the literature despite the scarcity of ethnohistoric sources, codes and chronicles related to the period of contact between Indoamerican medical cultures and Iberian medical traditions. Most work has been carried out in the Mesoamerican region, especially Mexico, and in Peru. Archeological studies have been mainly related to bones (cranial trepanation techniques) and Precolombian ceramics. There are very few references to physical anthropology in the annotated bibliographies but this is probably because these studies are usually cited in other sources. Studies related to altered states spiritism
qf consciousness and
Another branch of medical anthropology is related to studies dealing with altered states of consciousness: spiritistic possession, trance, voodoo, have drawn the attention of psychologists, psychiatrists and anthropologists who have worked in Haiti, the West Indies, Puerto Rico and parts of Brazil. Although there is evidence of states of possession and trance in South America, especially amongst the Aymara of Bolivia, central Chile, Patagonia in Argentina and Amazonian areas in Brazil and Venezuela [27], no references are made to studies in these areas. Spiritism or kardecism which was introduced in the second half of the 19th century from France to Brazil gave rise to religious manifestations with an increasing number of followers: faith healing, and treatments, interventions and operations described as ‘miraculous’ or magic, carried out by a medium or persons in state of trance are examples of such manifestations. These phenomena have been reported widely by esoteric writers and in popular literature. There are very few scientific writings, however, which have made objective observations and follow-up of cases, and perhaps this is an area which should be explored more systematically in the future. especially
DUNCAN PEDERSENand VERONICA BARUFFATI
10
in Brazil, in an attempt to examine more closely the healing processes outside the conventional medical therapeutics and which cannot be explained within the naturalist framework. Comparative works on the effects of spiritist and psychiatric treatment amongst Puerto Rican immigrants in New York by authors such as Alan Harwood and Vivian Garrison [28,29] have yielded important data and opened up the way for carrying out controlled experiments in certain parts of the Caribbean and South America. Ethno-obstetric
studies
The field of traditional obstetrics and ethnoobstetrics seems to be well-defined. There is more consensus amongst the population, parturients and researchers (anthropologists and physicians) about obstetric categories related to delivery care, and the concepts, values and behaviour related to delivery than about categories, concepts and behaviour related to health and disease. In Harrison and Cosminsky’s bibliography, references to ethno-obstetric studies on delivery are surprisingly scant for Latin America and practically non-existent for the Caribbean region. Traditional birth attendants receive but a handful of references (8 titles) despite intense training programmes run by the official sector. More recognition should be given to this resource. In the PAHOjWHO bibliography, there are 35 titles related to ethno-obstetrics and TBAs, including some on herbalist abortions and contraception. Many of these ethnographic descriptions of delivery care allow us to make a favourable comparison between some traditional delivery care practices and modern obstetrics and perinatology. However, no evaluation studies have been carried out on traditional obstetrics nor research to measure the impact of these practices in controlled studies on maternal and perinatal morbidity and mortality. Modern technology apportioned to the TBA has not always been used as physicians and nurses, who were involved in their training and modernisation of deiivery, expected. The evaluation of traditional obstetrics, of TBAs and training methods, and of the technology used in delivery care is a priority area which should precede action programmes in this field. The comparative approach
medical
systems
and transcultural
Studies comparing medical systems are relatively scarce in Latin America and the Caribbean although the last few years has seen an increase in this area. Transcultural or intercultural studies also represent a minority (22 titles in the Harrison and Cosminsky’s bibliography). The approach of comparative studies is basically empirical, and as in other parts of the world, these studies have dealt mainly with popular knowledge related to the denomination of illnesses, the explanatory model and causality. There are only a few comparative studies in the Latin American region related to the people’s behaviour in preserving health and managing the disease situation amongst different ethnic groups and in relation to different co-existing medical systems. It is paradoxical that no study in the period covered by both bibliographies (1950-1979) has tried to compare the effectiveness between the
two medical systems (traditional and modern) or between the different therapies of TMCs with the aim of establishing a more objective comparative basis between shamans and physicians. herbs and drugs. medical procedures and therapeutic rituals. allowing better orientation for future action in the held of medical systems and TMCs. The first comparative study of results of treatment administered by physicians and healers was reported recently by Kleinman and Gale in a study carried out in 1977 with a follow-up of 118 cases dealt by ‘Western’ physicians and 112 by shamans in sanctuaries in Taipei, Taiwan [30]. This article, the first of its type [31], points out some of the limitations of such a study and the difficulties in design and methodology. Nevertheless. the therapeutic results reported are similar or better in those cases dealt by the shaman. In 1979, in a study we carried out in Ecuador and which is reported elsewhere [32], we determined health levels according to reported morbidity and the mortality experience of the population in communities with and without medical services. All communities had access to an important network of healers, sorcerers, herbalists and other non-professional specialists or healers. The health level, measured by mortality, turned out to be similar or worse in those communities with medical services and easy access to modern hospital facilities. This is because mortality levels are more related to economic factors, social stratification and environment than to density of physicians or healers per habitant. When we looked at coverage, physicians and healers were consulted in equal proportions in the case of a serious ailment. Finally, we followed up actual cases treated by healers and found that there was a significant rate of curing or improvement by the end of the treatment. However, as we did not do the same for cases treated by physicians we were not able to compare results of treatments by healers and physicians. The tendency here is consistent with the scant attention paid to comparative studies of medical systems elsewhere in the world. This may be due to the fact that most medical anthropology research has dealt with medical practices as a peripheral manifestation or as a dependent variable rather than a subject of real analytical interest [33]. On the other hand, as knowledge of TMCs has been divesting itself of its exotic garments and has come to form part of a daily reality in the life of Latin American peoples, we must also admit that-as elsewhere-a romantic myth has been created around the healers, as if they were infallible wise men who possess the understanding needed by physicians and Western medical practices [34]. This image of mistaken idealisation can no longer be upheld, as it is utopian to expect that healers can come up with the correct solution for all society’s health needs, just as it is naive to insist that medicalisation is the only valid response to achieve optimum health in society. TOWARDS THE CONSTRUCTION OF BIO-SOCIO-CULTURAL .MODELS
The contributions that social sciences and anthropology can make to health care strategies, clinical and preventive medicine and to the training of human
Health
and traditional
resources in health would be much greater if, on the one hand, we left behind the idealisation of TMCs and, on the other, we broadened our view of the extreme medicalisation of daily life. The dilemma of adhering to a naturalist conception and to biochemical models of interpreting health and disease or of relating these processes culturally, are part of the wider dilemma which exists between the natural and social sciences, or to be more precise between biology and culture. In order to reach a better understanding of the dialectical relation between biology and culture, we should see man not only as a biological being who lives among a specific human group, but rather as both carrier and creator of culture [35]. Likewise, we should also recognise the huge variability of cultural strategies created and developed by different human groups in their exchange with the environment of which TMCs form part. Biology and culture are at the very centre of the fundamental ‘project’ of anthropology and medicine. Today we have to admit that the relations between biology and culture have gone through different phases where opposition usually predominates. If we consider the relationship between biology and culture as two opposing but closely related trends today, we can divide anthropological research related to health and disease into two main types: the biological approach and the cultural approach.[35]. The former is related to physical anthropology which is mainly interested in population genetics, anthropometry, comparative anatomy, where adaptation and evolution and their relation with ecology are of utmost importance. The latter is upheld by socio-cultural anthropology which deals with the understanding of the role of culture in society, life styles, the cultural basis of diet. the popular interpretation of disease, the behaviour of the population vis-h-vis health services, etc. According to Bibeau, this orientation has three basic approaches: (a) that which concentrates on what a specific group says about health and disease: the denomination, identification, classification, explanatory model, etc. This contributes basic knowledge to any project related to education or clinical prevention or intervention; (b) that which deals with what a specific group does to preserve and maintain health and fight disease: lifestyles, practices and behaviour in the search for health, which is most closely related to a socio-cultural epidemiological approach: and finally (c) that which looks at the socio-economic determinants and cultural conditioners of morbidity and mortality, and at the different morbidity-mortality patterns in various ethnic groups and cultures. The dilemma existing between biology and culture, and between social sciences and medical sciences is far from being solved, but a way is beginning to open up with the attempts to construct a comprehensive model allowing better articulation between biological data on the one hand. and psychological, social and cultural data on the other [36]. These attempts are underway with the contribution made by researchers such as Eisenberg [34]. Kleinman [37], Good and DeIVecchio [38] and others. We must, however, recognise that the success of these efforts is as yet limited, and is mainly related to clinical medicine. In
medicine
II
cultures
the meantime, specialists and professionals in the health sciences must recognise and implement the contributions the social sciences can make for a better understanding of health, medicine and medical systems, including disease and healing; and likewise, medical anthropologists and social scientists should participate in and learn from the needs and vicissitudes of the daily tasks of public health, and clinical and preventive medicine, in order to be able to make a more objective contribution to a common cause. Our basic task for the Latin American and Caribbean region is not to reduce the role of biological sciences in the theory and practice of medicine and medical systems, but rather to ensure the application of social sciences and medical anthropology in the construction of an epidemiological, bio-sociocultural model to help understand the natural history of disease and enrich medical systems qualitatively in the development of more humane and efficient interventions, both in the clinical field as in the field of health policies and strategies for the Latin American people. REFERENCES
medical culture I. Young A. The relevance of traditional to modern primary health care. Sot. Sci. Med. 17, 1205-1211. 1983. 2. Engei G. L. The need for a new medical model: a challenge for biomedicine. Science I%, 129-136, 1977. Sot. Sci. Med. 12, 65, 1978. 3. Leslie C. Introduction. 4. Press I. Problems in the definition and classification of medical systems. Sot. Sci. Med. 14B, 45-57, 1980. 5. Landy D. (Ed.) Callure, Disease and Healing: Studies in Medical Anthropology. Macmillan, New York, 1977. 6. Leslie C. Medical pluralism in world perspective. Sot. Sci. Med. 14B, 191-195, 1980. 7. Leon L. A. La medicina en la epoca colonial. Reuisfa Terapia. Laboratorios Life, Quito, 1974. aphcado a 8. Pedersen D. et al. El metodo epidemiologico la evaluation de la medicina traditional. In Epidemiologia y Salud Ptiblica (Edited by Mazdfero V. E.). Buenos Aires, 1982. sources, published in 1950 and 1967 9. Two bibliographic in Mexico and Colombia respectively, have not been included in this revision because we have been unable to get hold of them: Guerra F. Bibliografia de la Muteria Medica Mexicana. La Prensa Midica Mexicana, Mexico D. V., 1950; Seijas H. A preliminary bibliography on Colombian ethnomedicine. Etnoiarria 1, No. 2, 1967. 10. An excellent revision of this material was made by Allan Young in this compilation of 189 titles in No. 1 I of A. Rec. Anthrop. 1982. I. E. and Cosminsky S. Traditional Medicine: 11 Harrison Implications for Ethnomedicine, Ethnopharmacology, Maternal and Child Health, and Public Health. An Annotated Bibliography of Africa, Latin America and the Caribbean. Garland, New York, 1976. edition 12 In 1983, a second, more complete, up-dated appeared including titles published as recently as 1982. Bibliografia Seleccionada en An13. PAHO/WHO. tropologia Medica para 10s Profesionales de la Salud en las Americas. Field Office/Mexico-U.S. border. El Paso, TX, 1978. Medicina Traditional. Serie Biblio14. BIREME/PAHO. grafica No. 3, Sao Paulo, 1978. A. Bibliografia Comentada de la Medicina 15. Ramirez Traditional Mex&a (1900-1978). Monografias Cientificas III. IMEPLAN. Mexico. 1978. 16. Badgley R. F., Bravo G., Gamboa C. and Garcia J. C. Bibiiografia Latinoamericana sobre Ciencias Sociales
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Aplicadas a Salud. PAHO/WHO, Washington, DC, 1981. 17. GIRAME. Sante. Culture, Health: Bulletin d’information en Anthropologie Medicale et en Psychiatric Transculturelle, Vol. 1, No. 2, 1983. and Cosminsky; and 18. There are 115 titles in Harrison more than 140 in the PAHOjWHO bibliography. 19. A good idea of this distortion can be had by comparing the WHO approved list of Basic Medicines for the treatment of most diseases in the Third World with the number of specific medicines on sale in these countries . (e.g. in Ecuador 15,000 products have been approved for sale; and in Mexico, an estimated 80,000 specific medicines are on the market). 20. Ferguson A. E. Commercial pharmaceutical medicine and medicalization: a case study from El Salvador. Cult. Med. Psychiat. 5, 105-134, 1981. W. C. Studies in ethnoscience. In Trans21. Sturtevant cultural Studies in Cognition. pp. 99-131. Anthropological Approaches, Part Three, 1966. H. The need for an ethnomedical science. 22. Fabrega Science 189, 969-975, 1975. y sociedad: las corrientes del 23. Garcia .I. C. Medicina pensamiento en el campo de la salud. Educ. Med. Salud 17, 380, 1983. J. Medicine and culture: some anthro24. Comaroff pological perspectives. Sot. Sci. Med. IZB, 247-254, 1978. last publication in Educacidn 25. In Juan Cesar Garcia’s Medica y Salud he characterises the phenomenologists as those who believe that healing is based on shared values, symbols and meaning. Garcia sharply criticises this phenomenological position for attempting to “convert the consumer of medical attention into its supplier by means of self-care or participation in its intermediary structures .“. Ethos 10, No. 4, 26. Prince R. Shamans and endorphins. 1982. E. World distribution and patterns of 21. Bourguignon possession states. In Trance and Possession States. (Edited by Prince R.) Proceedings of the Second Annual
28.
29.
30.
31.
32.
33.
34.
35. 36.
37.
38.
BARUFFATI
Conference. R. M. Bucke Memorial Society. Montreal. 1966. Harwood A. (Ed.) Practical and theoretical implicatton of spiritist beliefs and practices. In Rs: Spiritisr as ‘Veeded. Wiley. New York. 1977. Garrison V. The Puerto Rican Syndrome in Psychiatry and Espiritismo. In Case Studies in Spirtr Possesston (Edited by Crapanzano V. and Garrison V.). Wiley. New York. 1977. Kleinman A. and Gale J. L. Pattents treated by physicians and folk healers: a comparative outcome study in Taiwan. Cult. Med. Psychtar. 6, 4051123. 1982. The need for evaluating traditional mei line practices in general and in relation to mental illnesses was foreseen by H. B. M. Murphy in a presentation he made in October 1974 on folk healing in Bahia. Brazil at a meeting organized by PAHO/WHO and the National Division for Mental Health. Murphy’s paper was entitled “Approaches to the Evaluation of Folk-Healing Practices”. Pedersen D. and Coloma C. Traditional medicine in Ecuador: the structure of the non-formal health systems. Sot. Sci. Med. 17, 124991255. 1983. Young A. Some implications of medical beliefs and practices for social anthropology. Am. .4nthrop. 78, 5. 1976. Eisenberg L. and Kleinman A. (Eds) The Relevance of Social Sciences for Medicine. D. Reidel. Dordrecht. 1980. Bibeau G. Hacia una conceptualization de la antropologia medica. Sante, Cult. Hltlt I, No. 2 1983. Bibeau G. Current and future issues for medical social scientists in less developed countries. Sot. Sci. Med. ISA, 351-370, 1981. Kleinman A. Medicine’s symbolic reality: on a central problem in the philosophy of medicine. Inquiry 16, 209, 1973. Good B. M. and Delvecchio Good M. J. The meaning of symptoms: a cultural hermeneutic model for clinical practice. In The Relevance of Social Sciences for Medicine (Edited by Eisenberg L. and Kleinman A.). D. Reidel, Dordrecht. 1980.
