CO
in
O
CM
o
X
Common Health Care Beliefs and
Practices of Puerto Ricans, Haitians
and Low Income Blacks Living in the
New York/New Jersey Area
5°
I £
O '5
Q) <*>
O) „
"O Q)
CD C
o -*
C >>
DC 0)
J- CO
CO
m
CO
o
CM
O m
m
CM
CD
m «t
<D O
= o
> 00
-* '
o -r~'
o
(X
&
A Training Module Developed For The
Public Health Service Region II
National Health Service Corps
The Department of Health and Human Service
Reprinted By The Office of Minority Health
Public Health Service, Region II
J
"- o
Common Health Care Beliefs and
Practices of Puerto Ricans, Haitians and
Low Income Blacks Living in the
New York/New Jersey Area
I. Introduction to Cross Cultural Health Care
II. Common Health Beliefs and Practices of Puerto Ricans
III. Common Health Beliefs and Practices of Haitians
IV. Common Health Beliefs and Practices of Low Income Blacks
Public Health Service
Region II
26 Federal Plaza
New York, NY 10278
(Reprinted by the Office of Minority Health PHS Region II)
John Snow Public Health Group, Inc.
Under Contract with: NHSC/DHHS/Region II
Contract No. 120-83-0011
I. INTRODUCTION TO CROSS CULTURAL HEALTH CARE
A. INTRODUCTION
National Health Service Corps (NHSC) providers are frequently assigned
to health centers serving large minority populations with socio-cultural
characteristics quite different from their own and those of the majority
population* These centers are usually located in communities where one or
more ethnic group(s) predominate and often the center's support staff
reflect the community's composition and culture. A major part of every
culture is a health belief and practice system, i.e. , ideas about body
image and anatomical functioning, disease causation, symptoms, diagnosis,
appropriate treatment and prevention of disease (Weaver & Sklar, 1980).
Cultures differ in their medical belief systems such that what is perceived
as illness, its causes and proper treatments and appropriate sick role
behavior, varies widely from one culture to another (Weaver & Sklar, 1980).
When members of one culture provide health care to members of another
culture, conceptual misunderstandings are likely to occur (Weaver & Sklar,
1980). The needs and expectations of both parties are not mutually shared.
As a result, patients may receive medical care inconsistent with their
world view and mainstream providers are often hindered in their attempt to
provide care they consider effective and rational.
Cross-cultural misunderstandings about health care are even more
likely when patient and provider do not share a common language. This is
often the case in multi-ethnic NHSC sites. Providers must overcome yet
another major barrier to achieving an accurate diagnosis and treatment and
convey this information to patients. All of these factors contribute to
the likelihood of less than optimal outcomes when a patient and mainstream
provider come face to face. In order to treat patients from
socio-cultural lv different backgrounds and communicate effectively with
them, providers must develop a special understanding of the health beliefs
and practices of their ethnic patient populations. More importantly, they
must also develop methods for optimizing the communication flow and
treatment results of these encounters.
B. PURPOSE
The intent of this booklet is to provide an orientation for NHSC
physicians to the health beliefs and practices of their ethnically diverse
patient populations, to increase understanding of the health belief systems
and to thereby facilitate better treatment outcomes in these cross-cultural
encounters. It should be cautioned that by no means do all members of a
particular ethnic group share the beliefs and traditional practices
mentioned herein. There are different levels of belief in and adherence to
all the practices mentioned, ranging from none at all to fervent practice.
C. METHODOLOGY
The information presented herein was obtained by The John Snow Public
Health Group, Inc. (JSI) from three major sources: 1) discussion with
researchers and health professionals working in multi-cultural settings;
2) a review of the recently published relevant literature; and 3)
discussion with patients, staff and nonpatients from multi-ethnic health
1-2
centers. (JSI organized focus groups for the purpose of obtaining culture
specific viewpoints about health care and consisted of patients,
nonpatients or staff of NHSC sites in Region II. Separate groups were
organized for each ethnic group: low income Blacks, Puerto Ricans, and
Haitians.) JSI conducted the study between October of 1983 and March of
1985.
D. COMMON CONCEPTS IN FOLK MEDICAL SYSTEMS
Most folk medical systems have many conceptual similarities, and it is
useful to look at these before studying the specifics of a particular
culture's beliefs.
1. Generally, folk healing systems divide the causes of
disease into two types: natural and unnatural. The first
type are those caused by the environment or natural
inbalances in the body's physical, emotional or
psychological state. The second are those due to the
malicious desires of another person enacted through a human
agent using witchcraft rituals or those due to the actions
of displeased spirits, gods or ancestors (Weaver & Sklar,
1980).
2. In conceptualizing disease causation, most folk healing
systems do not have a mind-body dichotomy as does western
medicine. Folk medical systems often have multi-causal
explanations for a disease which frequently include an
emotional, psychological or social component (Weaver &
Sklar, 1980).
3. Folk medical systems have specialized healing personnel.
Often these personnel are distinguished by the types of
illnesses they cure — i.e. , natural or unnatural.
4. In folk healing, both healer and patient have active roles
and share similar expectations in the healing process.
5. Folk healers may have unquestioned power and authority and
are expected to bring about cures in a relatively short
period of time.
6. Suggestion and hypnosis are used extensively in folk
healing and are important elements.
7. Folk healing usually provides a common idiom for naming the
disease and an explanatory strategy which gives answers to
and images of the disease and cure process.
8. There are specialized healing behaviors in each folk
system, that is, special expected behaviors for diagnosis
and treatment.
9. Each system also has generalized and specialized medical
substances. Generalized substances are those commonly
1-3
conceived of as "home remedies." Specialized ones are those
prepared, prescribed, or used by healing specialists.
10. Finally, folk medical systems also include some fee
structure and arrangements for payment to the healing
personnel.
Many of these concepts are also common to western, scientific medical
systems. Specifically, the U.S. mainstream medical system has specialized
healing personnel, specific idioms and explanatory strategies for disease,
expected diagnostic and treatment behaviors, generalized and specialized
medical substances and arrangements for payment. These common features may
help physicians in developing a framework for the many variations of
traditional healing systems and provide a common ground for achieving
desired treatment outcomes.
These commonalities may bring one to oversimplify traditional belief
systems and providers should be careful not to make this mistake. Although
many belief systems share a common structure, they are not at all
homogenous. There are multitudinous variations among cultures and even
within one social group. The specific practices around the common
framework are quite different from culture to culture and the specifics can
be extremely important in treating any one individual.
E. ACHIEVING OPTIMUM TREATMENT OUTCOMES WEEN PATIENT AND PROVIDER
ARE OF DIFFERENT CULTURES
In working with persons of different cultures, it is important to keep
in mind that there will be variations among individuals in their adherence
to a traditional medical system. These variations will be due not only to
personal belief differences but, with a cultural group that has recently or
is still immigrating to the U.S., also to differing degrees of
acculturation.
Immigrants have had substantial experience in a healing system of
another country and culture and have learned to expect treatment to occur
in certain ways and personnel to behave in a certain manner. Now, living
in the United States, they must use the mainstream medical system or, if
they believe in folk medicine, must fall back on folk healers and medicines
available in their community. An example of this dilemma is evident in the
account given by a woman from Trinidad who participated in one of the
patient focus groups for this project. She was treating herself for a rash
by rubbing honey and vaseline on it. It became worse. When she didn't see
any change she went to the doctor and told him what treatment she was
using. He told her she should "leave the treatment to the doctor." She
told him that in Trinidad, there are no doctors so she learned to treat
herself. She became very upset with the physician and left.
Scott (1974) states that when subordinate groups are only partially
assimilated into a dominant culture, they tend to be bicultural in their
choice of alternative beliefs and behaviors. People from a different
culture are caught between two worlds, often believing in the folk causes
1-4
and treatments of disease, but now living in a country where these beliefs
are not the norm and where a physician's medicine is viewed as more
powerful.
There is much evidence to support the fact that many persons who
believe in folk healing systems use several healing personnel (both
traditional and mainstream) simultaneously or sequentially. Mainstream
health providers may be consulted to see what treatment they offer, to
verify a folk healer's diagnosis, or to unknowingly confirm a "spell" or
hex. Thus. appearance in a mainstream medical center does not
automatically imply confidence or belief in that system.
Due to the differences in acculturation there are also variations in
belief systems through the generations. First generation and elderly
members of a culture are more likely to follow traditional beliefs.
Succeeding generations, however, are likely to recall and use some of
"mother's remedies" when sick even though they may not have had the
associated folk "training."
In our pluralistic society, providers thus have a broad continuum of
traditional health beliefs with which to contend. A variety of methods are
available to these providers when communicating medical information to
ethnic individuals. The physician's own personality and temperament will
also come to play in formulating his or her own style. A provider may
choose to "educate" the patient to bring them to understand the logic of
the regimen, may (according to personal style) use his or her authority to
establish a treatment regimen or may choose to work within the patients
belief system. Each of these methods may be appropriate on occasion, but
behavioral science shows that the most effective will be working within the
patient's belief system (Harwood, 1971).
Efforts to change a person's beliefs, attitudes and behaviors about
illness and its proper treatment in a short time period are not likely to
succeed, especially when the patient is surrounded by people who share his
beliefs. The ability to make these changes is, of course, dependent on the
particular individual, and providers must make judgements and adjustments
to their particular methodology in each case.
II. PUERTO RICAN BOOKLET
II. COMMON HEALTH BELIEFS AND PRACTICES OF PUERTO RICANS
LIVING IN THE NEW YORK/NEW JERSEY AREA
This booklet on the health beliefs and practices of Puerto Ricans
living in the New York/New Jersey area is divided into four major sections.
The first deals with concepts of disease and illness, the second with the
use of home remedies and traditional healing practices, the third with
attitudes toward and use of mainstream health providers and the fourth with
implications for effective treatment of Puerto Ricans by mainstream
providers.
As discussed above, information for the booklet was gathered from
three sources; the booklet is an attempt to integrate the information
gathered from these sources and to provide NHSC practitioners with
information they can use to provide culturally sensitive health care to
Puerto Rican patients. A caution is worth repeating at this point:
providers should not assume that all, or even most, Puerto Rican patients
ascribe to the beliefs and practices discussed in the following pages.
Rather, the information should point to conditions that they might watch
for. In addition, the results of the focus groups JSI held with NHSC
sites' patients and staff members lead us to conclude that patients are
more likely to follow the treatment recommendations of providers who have
shown some interest in and consideration for their cultural beliefs and
practices.
A. CONCEPTS OF DISEASE AND ILLNESS
Puerto Ricans, like members of many other cultural groups, may have a
holistic conception of health and illness. Many feel that the physical and
mental functionine of the body cannot be separated; what affects one will
affect the other. Thus, a person's health is subject to feelings, other
peoples' actions, significant events, natural forces and spirits. A
logical extension of this holistic approach is the belief that faith in God
and the healer are vital to being healed. This belief was also confirmed
by the members of the Puerto Rican patient groups convened for this study.
Some Puerto Ricans believe that illness is the result of either
natural or supernatural causes. A natural illness is caused by "cold,"
"empacho" or any other similar event, or is seen as having been permitted
by God. A belief in the supernatural causes of illness, or spiritism, is
based on a belief that spirits can enter the visible world and influence
human behavior. A person affected by spiritism is not considered sick but
is seen as suffering from a "causa" and is not blamed for the condition
(Comas-Diaz, 1981). Witchcraft is a general term which covers a range of
supernatural factors causing illness or some other negative occurrence.
Jealousy frequently plays an important role in witchcraft, "dano" (harm)
may be the result of another person's envy and is particularly important as
a cause of "nervios." For example "mal de ojo" (evil eye) is explained as
the rapid onset of an illness in children and is believed to be caused by
an adult who covets an attractive or clever child.
II-2
Discussions with Puerto Rican patients. nonpatients. and staff
indicated that although beliefs in spiritual causes and cures of illness
do exist to a certain extent and particularly among people who have
recently arrived in the United States, they are not prevalent among Puerto
Ricans living in the New York/Nev Jersey area. Providers should not assume
that their patients believe in spiritual causes of illness or that patients
are imagining their illnesses.
Practitioners who deal with the effects of spiritism and with
witchcraft will be discussed in Section B. In addition to the beliefs and
practices that would be recognized both by holders of mainstream and
traditional beliefs, the following theories and illnesses may be recognized
by Puerto Ricans living in the New York/New Jersey area.
1. The Hot-Cold Theory Of Disease
The following discussion is based primarily on Harwood's 1971 article:
"The Hot-Cold Theory of Disease." The Hot-Cold Theory of Disease is one
which is considered to be prevalent in almost all Latin American cultures.
It has been found among Puerto Ricans in the New York area and, for those
who practice it, has significant health care implications. The hot-cold
system is derived from the Hippocratic humoral theories of disease which
were brought to Latin America by the Spanish and Portuguese in the 16th and
17th centuries. According to the Hippocratic theory, there are four bodily
humors (blood, phlegm, black bile and yellow bile) and these humors vary
both in temperature and moistness. Health is considered to be a state in
which all four humors are in balance in a wet and warm body. Disease is a
state in which one or more of the humors are out of balance. Foods, herbs
and medications are classified as wet or dry, hot or cold and are used
therapeutically to restore the body to its natural balance. In the Puerto
Rican variation of the Hot-Cold Theory, diseases are classified as either
hot or cold, but food and medicines are categorized as either cold, cool or
hot.
The classification of foods is not related to the temperature at which
they are normally ingested. For example, lima beans and steaming hot
linden tea are classified as "cold" foods. An ice cold beer, on the other
hand, is considered a "hot" food. Temperature is important, however, in
the believed etiology of the disease. Illnesses classified as "cold," for
example, are often thought to be caused by the person being chilled. The
common cold is often believed to be caused by drafts, and upset stomachs
and may be attributed to eating too many "cold" foods which chill the
stomach.
The system can be individualized so that if a food or medicine that is
typically classified as "cold" causes symptoms that are classified as
"hot," the individual may classify it a "hot" food for himself /herself .
Table 1 gives categorizations of illnesses, medications, foods
according to the hot-cold theory and Table 2 elaborates on the expected
behavior of patients who adhere to the hot-cold theory.
Treating patients who believe in the hot-cold theory of disease can be
a challenge for health providers. One dilemma that may arise is that
TABLE 1
THE HOT-COLD CLASSIFICATION AMONG PUERTO RICANS
1 1-3
Illnesses or
Bodily Conditions
"Frio" (Cold)
Arthritis
Colds
("Frialdad del
estomago")
Menstrual period
Pain in the joints
("Pasmo")
"Fresco" (Cool)
"Caliente"(Hot)
Constipation
Diarrhea
Rashes
Tenesmus
Ulcers
Medicines and
Herbs :
Foods
Avocado
Bananas
Coconut
Lima beans
Sugar cane
White beans
Bicarbonate of soda
Linden flowers
("Flor de tilo")
Mannitol
("Mana" de Manito")
Mastic bark
("Allmacigo")
MgC03
("Magnesia boba")
Milk of magnesia
Nightshade
("Yerb Mora")
Orange-flower water
("Agua de azahar")
Sage
Barley water
Bottled mile
Chicken
Fruits
Honey
Raisins
Salt-cod
("Bacalao")
Watercress
Anise
Aspirin
Castor oil
Cinnamon
Cod liver oil
Fe tablets
Penicillin
Rue
Vitamins
Alcoholic
Beverages
Chili Peppers
Chocolate
Coffee
Corn Meal
Evaporated
Milk
Garlic
Kidney Beans
Onions
Peas
Tobacco
Reprinted by permission. Source: Harwood (1971), "The Hot-Cold
Theory of Disease." Journal of the American Medical Association,
216. Copyright 1971, American Medical Association.
1 1-4
TABLE 2
EXPECTABLE BEHAVIOR OF PATIENTS WHO ADHERE TO THE HOT-COLD THEORY
Patient's Condition
Common cold, arthritis, joint pains
Diarrhea, rash, ulcers
Requires a diuretic as part of a
treatment regimen and has been told
to supplement his potassium intake
by eating bananas, oranges raisins,
or dried fruit.
Requires penicillin or any other hot
medication, particularly on an
ongoing basis.
Infant requires formula, which
contains hot-classified
evaporated milk.
Pregnant
Postpartum and during menstruation.
Expectable Behavior
Patient will not take cold-
classified foods or medications,
but will accept those classed
as hot.
Patient will not take hot-
classified medications and
uses cool substances as therapy.
Patient will not eat these
cold-classified foods while he
has a cold or other cold-
classified condition. (For
female patients, this includes
the menses.)
Patient will stop taking hot
medicine when he suffers any
hot-classified symptom (e.g.,
diarrhea, constipation, rash).
Mother will put baby on cold-
classified whole milk or will,
after feeding formula, "refresh"
the baby's stomach with various
cool substances, some of which
are diuretic.
Avoids hot medicine and hot
foods and takes cool medicine
frequently.
Avoids cool foods and medicines,
particularly those which are
acidic.
Reprinted by permission. Source: Harwood (1971), "The Hot-Cold
Theory of Disease." Journal of the American Medical Association,
216. Copyright 1971, American Medical Association.
II-5
pregnancy may be thought of as a "hot" condition requiring the avoidance of
items classified as "hot" and the frequent ingestion of "cool" items.
Vitamins and iron pills are considered "hot" items and may not be taken by
a pregnant patient adhering to hot-cold concepts. Another common problem
is found in infant feeding practices. Evaporated milk, which is used in
infant formulas, is classified as a "hot" substance. Rashes, which are
common in young babies, are also classified as a" hot" condition and are
attributed to the intake of evaporated milk. One study found that over 40
percent of new mothers curtailed the use of evaporated milk upon coming
home from the hospital. These mothers either switched completely to whole
milk which is classified as "cold" or used the neutralization principle by
giving their babies a cool substance along with the evaporated milk. Some
of the cool substances used are barley water, magnesium carbonate (a
cathartic) and mannitol (a diuretic). They are believed to neutralize the
harmful effects of the evaporated milk. Providers might want to reinforce
the use of harmless substances such as barley water to mothers who are
using this principle.
The neutralization principle is an important one because it can be
used by practitioners to improve compliance in patients who believe their
prescribed therapy to be counter to the hot-cold theory. For example,
providers might suggest that their pregnant patients take vitamin and iron
tablets ("hot") with fruit juice or herb tea ("cool") to neutralize the
"hot" effects. Puerto Rican patients do not refer to this as
"neutralizing" but rather as "refrescando el estomago" — refreshing or
cooling the stomach.
Many principles of the hot-cold theory are in accord with orthodox
medical practice and thus, the hot-cold theory need not be viewed as a
major obstacle in patient care. In fact, the hot-cold system is, more
often than not, consistent with the practice of good medicine. Examples of
this are that the bland diet typically recommended for patients with ulcers
fits into the hot-cold system very easily and aspirin ("hot") is a readily
accepted treatment for colds and arthritis ("cold").
It is possible that, because of the influence of the hot-cold theory,
Spanish speaking cultures in general tend to feel that diet is a very
important component of any treatment modality. For this reason, they may
often expect suggestions about the proper diet that persons with their
condition should follow. The typical Puerto Rican diet includes rice,
beans, fatty meats, salted fish, milk and limited amounts of vegetables.
Iron, green vegetables and fruits may be lacking in the diet. "Tonicos"
(tonics) such as eggnogs or malted drinks may be taken for extra strength.
The Puerto Rican concept of a healthy diet may involve more calories and,
as a result, a higher body weight than an American physician might
recommend.
2. Illnesses Specific To The Puerto Rican Culture
There are several illnesses or conditions which researchers have found
to be specific to the Puerto Rican culture (Harwood, 1981 and Azziz, 1981).
Some of these are given below:
II-6
a. Empacho (obstruction or upset stomach) is caused by
excessive food intake, particularly heavy or starchy food.
According to Azziz (1981) it is consistent with gastroenteritis.
b. Mai aire (bad air) is the result of exposing an
overheated body to a cold wind or to cold water. Symptoms
include back pain, muscle contractions (spasmo) . and eventual
muscle paralysis.
c. Caida de mollera (fallen fontanel) is caused by a
"dislodgement" of the fontanel and results in a baby becoming
anorexic and lethargic. The symptoms are consistent with the
symptoms of dehydration which may be the result of excessive
vomiting or diarrhea.
d. Susto (fright) is the result of a frightening event
that causes a person's spirit to leave his or her body.
Symptoms include paleness, listlessness, withdrawal, anorexia
and weight loss.
e. Ataques (attacks) sometimes known as the Puerto Rican
Syndrome is a type of hysterical reaction with symptoms that
include seizures, acute stress and anxiety.
f. Malhiimor (bad humor) is used in a number of contexts.
It describes a blood condition that causes ongoing skin
conditions. It is also said that menstruating women have
malhumor and cause babies to have diarrhea if they handle them.
Some terms for certain illnesses and conditions also have a high
potential for being misunderstood in translations. Table 3 provides a list
of these potentially misleading terms.
One area of common medical concern and of high potential for confusion
is blood pressure. Discussions of blood pressure problems can easily be
misunderstood when dealing with a Puerto Rican persons because thev have
several terms which, when literally translated, are "high blood pressure"
and "low blood pressure" though their meaning in the Puerto Rican culture
is quite different than that intended by a practitioner of western
medicine. Alta presion (high blood pressure) is generally interpreted as
too much blood or polycythemia. Baja presion (low blood pressure)
generally means anemia. It is important for the practitioner to carefully
explain his/her meaning when diagnosing high or low blood pressure. Cancer
and tuberculosis also evoke a strong emotional response in many Puerto
Ricans. This has implications for how the practitioner should present the
diagnosis to the patient and his or her family. Tuberculosis has a strong
stigma attached to it and because of this, patients may sometimes refer to
it by another name, such as anemia.
3. Concepts of Mental Illness
There appear to be two basic categories of mental illness in the
Puerto Rican culture: locura (insanity, craziness) and nervios or
enfermedad de los nervios (sickness of the nerves) (Harwood, 1981). Either
1 1-7
TABLE 3
POTENTIALLY MISUNDERSTOOD SPANISH TERMS FOR
DISEASES OR PHYSICAL CONDITIONS
Spanish Term
"Acidez en el (del) estomago"
"Alta presion"
"Anemia en los hue so s"
"Asma"
"Ataque de alferecia"
"Ataque cerebral"
"Ataque de nervios"
"Baja presion"
"Catarro"
"Ceguera"
"Deficienca en la sangre"
"Empacho"
"Falfayota" (also "farfayota")
"Fatiga de ahogo"
"Fiebre paludica"
"Flu jo"
"Glandulas"
English Gloss
Stomach acidity, sour taste in
mouth and throat after eructa-
tion.
High blood pressure
Literally, anemia in the bones,
considered by many to be a form
of tuberculosis.
Asthma, can also refer to
shortness of breath from any
cause.
Convulsions in infants, thought
to be caused by sudden fright
("susto").
Stroke
Nervous attack
Low blood pressure, anemia
Cold, usually refers to one
localized in the chest.
Conjunctivitis, any inflammation
of the eye with exudate.
'Weak blood,' blood deficiency
Upset stomach, nausea,
attributed to a bolus of food
in the intestine.
Mumps
Asthma
Malaria, sometimes used to
refer to yellow fever.
Discharge, flow, particularly
from vagina.
Glands, swollen salivary glands
II-8
TABLE 3
(continued)
POTENTIALLY MISUNDERSTOOD SPANISH TERMS
Spanish Term
"Golondrino"
"Jaqueca"
"Mala circulacion"
"Nube en los ojos"
"Orisma" ("aneurisma")
"Pasmo"
"Quebraduras"
"Raquitis(mo)1*
"Resfriado"
"Reuma"
"Sangre gruesa"
"Sapo"
"Septicemia"
"Soplo en el corazon"
"Tuberculosis en los huesos"
English Gloss
Small underarm tumor or cyst,
said to occur in multiples.
Very bad headache, sometimes
accompanied by nausea; migraine.
Bad circulation, may be caused
by "sangre gruesa."
Cataract
Aneurysm
Spasm of clonic or tonic
variety, particularly facial
paralysis. Thought to be
caused by chills or drafts.
Hernia
Rickets; tuberculosis in
children.
Cold, usually refers to one
localized in the nose.
Rheumatism, used as a synonym
for arthritis.
Literally, "thick blood," blood
overly rich in red corpuscles,
polycythemia.
Thrush
'Pus,' or 'poison' in the blood,
often associated with leukemia.
Heart murmur
Tuberculosis of the bone, some-
times equated with rickets.
Reprinted by permission. Source: Harwood, Alan, Ethnicity and
Medical Care. Harvard University Press, 1981.
II-9
of these conditions may be the result of biological or spiritual causes or
of particular occurrences. People who suffer from locura behave
unpredictably and/or aggressively (this includes homicidal and suicidal
behavior) and may harm themselves; there is generally a stigma attached to
suffering from this condition. Nervios is identified by a number of
possible conditions including ongoing agitation, inability to concentrate,
pacing, excessive crying or brooding and is best treated, according to
tradition, by rest, relaxation, talking or medication.
One research team (Gaviria and Wintrob, 1976) report that the causes
of locura nervios can be divided into two categories: natural and
supernatural. The natural biological causes include alcohol and drug
abuse, heredity, malnutrition and head trauma. The natural psychological
causes include "desgaste" (weakness of the brain) due to such factors as
sexual excess, excessive worrying, thinking or obsessing, family problems,
and social problems — such as poverty or difficult working conditions.
Spiritism was found to be the most important supernatural cause of nervios
and locura. Witchcraft, bad luck, fate, "dano" (harm) and envy were also
found to be important factors.
B. USE OF HOME REMEDIES AND TRADITIONAL HEALING
Our research indicated that there is a significant amount of variation
in traditional health beliefs and practices among Puerto Ricans living in
the New York/New Jersey area. Overall, it appears that home remedies and
herbal medications are widely used and respected but that few people
believe that spirits cause or can cure illnesses. As mentioned in the
previous section, a very important distinction can and should be made
between the "natural" and "supernatural" traditions in Puerto Rican
culture. The two traditions are quite distinct; an individual can use
home remedies and go to traditional healers for "natural" illnesses without
believing in or practicing withchraft or sorcery. A mainstream provider
should not assume that the use of home remedies or traditional healers
means that a Puerto Rican patient is involved in witchcraft.
1. Home remedies
Home remedies are often used in conjunction with mainstream medicine;
mainstream providers should be aware that this is a possibility and should
provide patients with an opportunity to explain what remedies they are
using. Discussions with Puerto Ricans living in the New York/New Jersey
area suggest that patients are likely to believe that doctors will
disapprove of their use of home remedies; they may feel more comfortable
being questioned by staff. Staff members, in fact, may be very
knowledgeable about home remedies and traditional healers. In some cases
they may be dispensing information to patients and in almost all cases they
are a valuable source of information for the NHSC provider.
Oils and herbs are frequently used for home remedies and in
traditional healing practices. They may be obtained at a "botanica" or
sent directly from Puerto Rico. Botanicas are neighborhood herb shops that
stock herbal and spiritist remedies. The herbs sold for other than
11-10
spiritist reasons tend to be used for nervios and digestive, respiratory,
rheumatic, and genitourinary problems. The treatments supplied by
botanicas are often used in conjunction with treatments supplied by
mainstream providers. The following list includes commonly distributed
herbs :
Beneficial or neutral:
a. Aqua de azahar: orange-flower water (for nerves);
b. Tilo: linden tea (for nerves);
c. Yerba buena: peppermint (for digestive disorders);
d. Anis estella: star anis (for digestive disorders);
e. Manzanilla: chamomile (for digestive disorders);
f. Pasote: a laxative;
g. Glycvrhva elabra: licouce (a laxative);
Potentially harmful:
a. Aienio artemisa: wormwood, mugwort;
b. Laurel: laurel;
b. Correquela. Sanguinaria: bloodroot.
In addition to the herbs mentioned above, the following herbal
remedies were discussed at the focus groups held by JSI as part of this
study.
a. A mixture of several types of oils and onions is used in a bath
to cure a bad cold.
b. Watercress, ground and mixed with milk and sugar, is used to
treat tuberculosis;
c. The peel of bitter orange is mixed with salt and cooking oil,
left outside overnight, and eaten to treat malaria;
d. Aqua Benditas with Flores Blancas is used in a bath for pains in
the bones;
e. Lukewarm water, salt, and sugar are mixed together to make a
serum that is used to treat nerves ;
f. A piece of grass or the leaf of a tree is moistened, sprinkled
with salt and placed on a snake, spider or rodent bite;
g. Cooking oil is used to massage away an empacho;
h. A mixture of wheat flour, lemon, and sugar is used for "pujo"
(abdominal cramps which are similiar to the pain that preceeds
diarrhea) ;
i. Oils are used for ear infections;
j. Lemon and ginger teas are used to treat a cold;
11-11
k. Palode carajkon is a herb used to treat empacho;
1. A mixture of ground orange leaf, ginger, milk, and butter is used
to treat colds.
2. Traditional Healers
There are two basic types of traditional healers, those who deal with
supernatural illness and healing and those who treat natural illnesses.
Within these two classifications, the following traditional healers can be
identified:
a. Espiritista. bruieras and santeros treat illnesses that are the
result of spiritual causes or some combination of spiritual and natural
causes. Treatment may include purchasing candles, bathing with special
solutions and using protective fetishes and herbs to ward off evil spirits.
Most of the care provided by these healers is crisis oriented and lasts a
relatively short time. Common reasons for seeking this type of care
include insomnia, depression, nightmares, frequent crying, repeated
ataques. suicidal tendencies, problems concerning puberty, marriage,
menopause, chronic or terminal conditions, or other problems that another
type of provider has not been able to cure. Although some researchers have
drawn a parallel between psychotherapy and treatment by spiritual healers,
an important difference is that traditional psychotherapy is based on the
idea that individuals are responsible for and should take charge of their
behavior while espiritismo is based on the idea that individual problems
are the result of outside forces. Individuals effected by this type of
illness are not responsible for their illness and are expected to be
passive instruments of the treatment. Behavior that might appear to the
psychotherapist to be the result of an inability to cope may be a
culturally appropriate response for a Puerto Rican who has been influenced
by traditional health beliefs (Comas-Diaz, 1981).
b. Curandero is a general term used to describe healers who treat
natural illnesses such as dislocations, empacho (indigestion, blockage),
and mild digestive, respiratory, and rheumatic problems.. Curandero s use
herbs (see above section), "ventosas" (cupping), and massage. Massage, and
touch in general, are important healing technigues in Puerto Rican culture.
Massage is used as part of home treatment and by traditional healers, often
with special mixtures of oil. A skilled provider of care is said to have a
gift for healing, or a way of touching that is particularly effective.
c. Santiguadores are similiar to chiropractors in that a great deal
of their activity is based on massage and other manipulations of the body.
Although the word santiguador means "someone who blesses", the term has
come to be independent of interactions with spirits. "Santiguadores" treat
natural illnesses, particularly chronic and intestinal and orthopedic
problems (Azziz, 1981).
C. ATTITUDES TOWARD AND USE OF MAINSTREAM HEALTH CARE PROVIDERS
Discussions with Puerto Rican patients, staff, and nonpatients suggest
that, not suprisingly, Puerto Ricans living in the New York/New Jersey area
11-12
who seek care from mainstream providers would prefer to be treated by
Puerto Rican or Hispanic providers. This preference is both because of
language issues and because they feel that Puerto Rican or Hispanic
providers are more likely to understand and accept their belief systems and
use of home remedies.
We found that language barriers are common, even when native speakers
are available to translate. Misdiagnoses can occur because of
mistranslations (support staff may not always know how to translate medical
terminology) or because of cultural prejudices. Treatments may be
improperly followed because the patient did not understand and
prescriptions may be improperly used because the instructions were written
in English rather than Spanish.
There are a number of aspects of Puerto Rican culture which are
directly related to how Puerto Ricans living in the New York/New Jersey
area may view and utilize the mainstream health care system.
The family plays a central role in health practices and healing in the
Puerto Rican culture. Illness is a family affair and not just a problem of
the individual (Assiz, 1981). The family is an extended one including the
grandparents, godparents, in-laws and even special friends. Decisions
about whether a person is ill, what remedies they should use, whether they
should seek the services of a traditional or mainstream healer, and whether
they should follow that person's advice are all influenced by the opinions
of family members. An example of this family influence is seen in the
infant feeding practices of Puerto Rican mothers. The mother of a Puerto
Rican woman who is expecting a child often plays a major role in the
decision-making process surrounding infant feeding practices (Bryan, 1982).
Oftentimes, the new mother will live with her mother during the perinatal
period and the grandmother is the most important consultant in infant
feeding matters. The use of advice about infant feeding from these
individuals lessens with subsequent children. Still, a more subtle kind of
communication and influence will occur.
Another important aspect of the Puerto Rican culture is the concept of
"respeto" (respect), although this idea is a pervasive one in the culture
and is not important exclusively to health care. To treat others with
respect and to be treated with respect oneself are deeply held values. The
value of self is held very highly and lack of respect on the part of others
may be taken very seriously and have more pervasive consequences than the
offender would imagine. "Personalismo" is another related important
concept in Puerto Rican culture. Personalismo involves treating the
patient as an individual and building rapport before beginning the business
of the medical encounter. Puerto Rican patients expect a provider to show
his or her respect for them through the questions that are asked, the tone
of voice used and the way the provider touches the patient. A touch of the
arm, a pat on the back, or an embrace mav be highly valued, although warmth
should not be exhibited in a casual or informal way. While most Puerto
Ricans will respect a doctor because of his or her training and experience,
they will also expect the doctor to project the image of a doctor. A
provider should be well groomed and well-dressed and it should be obvious
that he or she is a doctor (white coat, black bag). The image the
physician projects should require and deserve respect.
11-13
One area where it may be particularly important for a provider to show
respect to the Puerto Rican woman is during exams for gynecological
problems. Puerto Rican women may have great feelings of shame and
embarrassment associated with sex and the female organs. In one study
concerning the contraceptive methods of several ethnic groups, Puerto Rican
women refused to label any parts of the female body between the navel and
the thighs (Scott, 1975). Members of the Puerto Rican patient discussion
groups held as part of this study reiterated this feeling of great shame
and embarrassment when undergoing pelvic exams. They expressed
appreciation for physicians who tried to put them at ease during the exam
by explaining what procedures they were doing and the reasons for them.
The same aforementioned study found that Puerto Rican women are more
likely to be using no contraceptive method at all, and if they are, it is
more often sterilization by tubal ligation. This use of tubal ligation for
contracepton has been found by other authors among the New York Puerto
Rican population and anecdotally by family planning personnel and
researchers in the New England area. One reason given for the pervasive
use of tubal ligation is that it is only "sinning" once, whereas most other
methods involve sinning with each sexual act. The research of the
contraceptive study also found that methods that alter the monthly flow,
such as the pill and IUD, are not as acceptable because a normal monthly
flow is believed to rid the body of "unclean" blood and is therefore
healthy and desirable. An interruption or change in this flow is
considered unhealthy and potentially harmful.
Another way that mainstream providers can show their respect for
Puerto Rican patients is to show interest in the patient's opinion about
his or her illness. Mainstream providers may find that Puerto Rican
patients have had and may be acting upon a preliminary diagnosis which is
based on a family member's opinion or the advice of a traditional healer.
Although Puerto Rican patients may expect providers to listen to their
opinion, they will not necessarily expect the provider to agree with the
diagnosis. A physician should work hard and earn the fee by ordering tests
and medicines; asking questions is not enough. Conversely, some Puerto
Rican patients will think that a provider who asks a lot of questions is
incompetent. Most Puerto Rican patients often want to talk about a range
of issues that may not be directly related to the problem that they are
seeing the provider for but which are viewed as critical by the patient.
The mainstream provider may feel that the peripheral issues are irrelevant.
Nonetheless, if time is available, listening to the patient's concerns may
increase the patient's respect for the provider and thus improve the
patient's compliance with the provider's treatment plan.
Some research ha6 shown that Puerto Rican patients and more generally,
Hispanic patients, may experience and present symptoms differently than
members of other cultures. When experiencing an illness, they may perceive
more symptoms and express a greater diversity of complaints than do
cultural groups of western and northern European origin (Weaver and Sklar,
1980). The mainstream provider may view this behavior as dramatization of
the illness and therefore as illegitimate illness behavior. The behavior
may confuse a mainstream health provider who may think that the patient has
an emotional problem when, in fact, the behavior can be attributed to
cultural norms.
11-14
A related issue that was raised in our discussion groups with Puerto
Rican staff members was that Puerto Rican patients may have difficulty
describing the type of pain that they are experiencing. This, of course,
may make it difficult if not impossible for the provider to accurately
diagnose the problem. The staff felt that the commumication problem went
beyond a language barrier to a different perception of the various types of
pain and of how that pain can be communicated.
D. IMPLICATIONS FOR PROVIDERS TREATING PUERTO RICAN PATIENTS OR WORKING
WITH PUERTO RICAN STAFF
As previously stated, it would be inappropriate for a NHSC provider
working with a Puerto Rican population to assume that all, most, or even
the majority of his or her Puerto Rican patients' health beliefs and
practices are described in the preceding pages. With this point in mind,
and recognizing that each provider has an individual style of practice, the
following list includes examples of situations or issues that might arise
when providing health care services to Puerto Rican patients or working
with Puerto Rican staff members.
1. A Puerto Rican patient may be already treating an illness
before coming to the mainstream provider and may continue to
use a variety of providers while being treated by a
mainstream provider. Treatment may be based on the opinion
of family members or on a diagnosis made by a traditional
healer. Information about other remedies should be
solicited directly by the provider or with the assistance of
a staff member.
2. If a mainstream provider is hesitant or unsure about a
patient's illness, that patient may seek care from a
traditional healer.
3. Mainstream providers should be aware that the family plays
an important role in diagnosing and treating illness. It is
likely that any diagnoses that are made and any treatments
that are prescribed will be discussed and interpreted by
more people than just the person being treated. In some
cases it may be appropriate to include the important family
member in the diagnosis and treatment sessions or to include
traditional remedies such as massage or herbal teas in the
treatment plan.
4. Mainstream providers might make an effort to touch the
patient several times during the medical encounter. A
handshake and a touch on the shoulder may go a long way
toward improving the quality of the encounter. In addition,
learning and using a few words of Spanish will lead to
greater rapport between the NHSC provider and the Puerto
Rican patient.
5. A Puerto Rican patient may expect that a thorough physical
examination be given for any problem.
11-15
6. Puerto Ricans may be distrustful if a lot blood tests are
ordered. In any event, providers should explain what
laboratory tests are being given, and why.
7. The provider may want to make sure that instructions for
treatment are given and written down in Spanish if the
Puerto Rican patient is not fluent in English.
8. A provider may want to determine whether an individual
practices the hot/cold system. This may be particularly
important for pregnant or lactating women.
9. The provider should not assume that his or her Puerto Rican
patients believe in the spiritual causes or cures of
illness. In most cases, the provider should not raise the
issue directly unless the patient has expressed such a
belief. Staff members may play a useful role in acting as
intermediaries in such cases.
10. Providers should be aware that the way that they are dressed
and their cleanliness will influence the seriousness with
which their Puerto Rican patients take their advice.
11-16
BIBLIOGRAPHY:
PUERTO RICAN HEALTH BELIEFS AND PRACTICES
Aiken, Linda H. (1976). Chronic Illness and Responsive Ambulatory Care.
In The Growth of Bureaucratic Medicine, ed. David Mechanic, New
York, Wiley.
Alers, Jose Oscar (1978). Puerto Ricans and Health. Findings from New
York City. Monograph No. 4, Hispanic Research Center, Fordham
University, Bronx, NY.
Azziz, Ricardo (1981). The Hispanic Patient. Pennsylvania Medicine
(July).
Bowering, Jeanet et al (1978). Infant Feeding Practices in East Harlem.
Journal of the American Dietetic Association. 72 (February).
Bryant, Carole Anne (1982). The Impact of Kin, Friend and Neighbor
Networks on Infant Feeding Practices. Social Science and Medicine
16.
Comas-Diaz, Lillian (1981). Puerto Rican Espiritismo and Psychotherapy.
American Journal of Orthophvchiatry 51, No. 4.
Delgado, Melvin (1979). Herbal Medicine in the Puerto Rican Community.
Health and Social Work 4, No 2. (May).
Galli, Nicholas (1975). The Influence of Cultural Heritage on the Health
Status of Puerto Ricans. The Journal of School Health 45, No. 1
(January) .
Garrison, Vivan (1977). Doctor, Espiritista, or Psychiatrist: Health
Seeking Behavior in a Puerto Rican Neighborhood of New York City.
Medical Anthropology 1 ,2.
Gaviria, Moises and Ronald M. Wintrob (1976). Supernatural Influence in
Psychopathology. Canadian Psychiatric Association Journal 21, No.
6.
Harwood, Alan (1971) The Hot-Cold Theory of Disease: Implications for
Treatment of Puerto Rican Patients. Journal of the American Medical
Association 216.
Harwood, Alan (1981). Mainland Puerto Ricans. In Ethnicity and Medical
Care. ed. Alan Harwood, Cambridge, Massachusetts: Harvard
University Press.
Haynes, R. Brian (1976). A Critical Review of the "Determinants of
Patient Compliance with Therapeutic Regimens". In Compliance with
Therapeutic Regimens, ed. David L. Sackett and R. Brian Haynes.
Baltimore: Johns Hopkins Universtiy Press.
11-17
(Bibliography/Puerto Rican, cont.)
Leiberman, Leslie Sue (1979). Medico-Nutritional Practices Among Puerto
Ricans in a Small Urban Northeastern Community in the United States.
Social Science and Medicine. 138.
Lubchansky et al (1970). Puerto Rican Spiritualists View Mental Illness:
The Faith Healer as Paraprof essional. American Journal of Psychiatry
127, No. 3.
Mumford, Emily (1973). Puerto Rican Perspectives on Mental Illness. Mt.
Sinai Journal of Medicine 40.
Padilla, Elena (1958). Up From Puerto Rico. New York: Columbia
University Press.
Ruiz, Pedro and John Langrod (1976). The Role of Folk Healers in
Community Mental Health Services. Community Mental Health Journal
12, No. 4.
Scott, Clarissa S. (1974). Health and Healing Practices Among Five
Ethnic Groups in Miami, Florida. Public Health Reports 89, No. 6
(Nov/Dec.) .
Scott, Clarissa S. (1975). The Relationship Between Beliefs About the
Menstrual Cycle and Choice of Fertility Regulating Methods Within
Five Ethnic Groups. International Journal of Gynecology and
Obstetrics 13.
Weidman, Hazel H. (1978). Miami Health Ecology Project Report: A
Statement on Ethnicity and Health. Department of Psychiatry,
University of Miami School of Medicine (Mimeo).
Wheeler, Madeleine and Sanober Q. Haider (1979). Buying and Food
Preparation Patterns of Ghetto Blacks and Hispanics in Brooklyn.
Journal of the American Dietetic Association 75 (November).
Yohai, Fanny (1977). Dietary Patterns of Spanish Speaking People Living
in the Boston Area. Journal of the American Dietetic Association 71.
EVALUATION OF NHSC BOOKLETS ON THE HEALTH BELIEFS AND
PRACTICES OF PUERTO RICANS AND
THE MEDICAL VOCABULARY GUIDE, QUE PASO?
After you have had a chance to read and use the booklet, we would
appreciate your comments about the usefulness of the booklet and the
medical vocabulary guide. Please take a fev minutes to complete this
evaluation and return it to:
Regional Program Consultant, NHSC
26 Federal Plaza
Room 3302
New York, NY 1027 8
A. Common Health Care Beliefs and Practices of Puerto Ricans Living in
the New York/New Jersey area
1. Did the information in this booklet increase your
knowledge about the health beliefs and practices of
Puerto Ricans?
2. If you have begun practice with a Puerto Rican
population, have you found the information contained in
this booklet to be useful to you?
3. Which sections were of the most interest and/or use to
you?
4. Is the booklet too long, too short, or about the right
length?
5. How did you read the booklet? Did you read the entire
booklet, selectively read the parts of most interest to
you, only read the underlined statements, etc?
6. Do you have any comments or suggestions for improving
the format or content of this booklet?
B. Que Paso?
1. Have you used the booklet?
2. If so, have you found the booklet helpful?
Well organized?
Comprehensive?
Easily understandable?
3. Which sectionCs) are you most likely to use?
4. How has using this book affected your relationship with your
patients?
With the staff that you work with?
5. Have you found other books of this type that are more
appropriate for your setting? Please list them (include name
and source).
III. HAITIAN BOOKLET
III. COMMON HEALTH BELIEFS AND PRACTICES OF HAITIANS
LIVING IN THE NEW YORK/NEW JERSEY AREA
This booklet on the health beliefs and practices of Haitians living
in the New York/New Jersey area is divided into four major sections. The
first deals with concepts of illness and disease, the second with the use
of home remedies and traditional healing practices, the third with
attitudes toward and use of mainstream health providers and the fourth with
implications for effective treatment of Haitians by non-Haitian, mainstream
providers.
As discussed above, information for the booklet was gathered from
three sources; the booklet is an attempt to integrate the information
gathered from these sources and to provide NHSC practitioners with
information they can use to provide culturally sensitive health care to
Haitian patients. A caution is worth repeating at this point: providers
should not assume that all, or even most, Haitian patients ascribe to the
beliefs and practices discussed in the following pages. Rather, the
information should point to particular questions that providers might ask
and to particular symptoms or conditions that they might watch for. In
addition, the results of the focus groups we held with NHSC sites' patients
and staff members lead us to conclude that patients are more likely to
follow the treatment recommendations of providers who have shown some
interest in and consideration for their cultural beliefs and practices.
A. CONCEPTS OF ILLNESS AND DISEASE
Many Haitians believe that illness is the result of either natural
causes or supernatural causes. Natural diseases occur frequently and are
usually over with fairly quickly. They are caused by purely natural
events: a person gets a cold; a worker is careless and cuts his finger
with a machete; a market woman carries an excessively heavy load and has a
miscarriage. Natural illnesses are divided into categories dealing with
blood, gas, human milk, bone displacement, disease movement, and hot/cold
disequilibrium. Supernatural diseases occur infrequently and appear
without any warning. They are believed to be caused by angry voodoo
spirits. Although many Haitian patients and staff members from New York
and New Jersey health centers expressed knowledge of spiritual causes and
cures of illness, few indicated a belief in or practice of witchcraft or
voodoo. Many expressed resentment that American health practitioners
assume that all Haitians believe in and practice voodoo, that they imagine
illnesses, and that they are all "a little bit crazy."
Irrespective of their belief in voodoo or witchcraft, belief in God
and in the healing power of that faith seems to be an important part of
Haitian culture. God can heal by working with the healer (the medical
doctor or the traditional healer) or through the sick person's dreams.
Faith in God and faith in the healer are both critical.
Another health belief that has important implications for primary care
providers is that many Haitians believe that a thin person is apt to be
sickly and a heavier person (by mainstream standards) is more likely to be
III-2
happy and healthy. The Haitian diet tends to be high in salt and fats;
common foods include salted and fatty meats, rice, beans, cornmeal,
potatoes, and plantain. Haitians may resist suggestions that they reduce
or change the types of foods that they eat (e.g. reduce salt or fats).
Haitian women may gain a considerable amount of weight during pregnancy
because they are encouraged to "eat for two." Providers working with
infants should be aware that babies may be given table food very young,
often by their fourth month.
In addition to the type of natural illnesses that would be recognized
both by traditional and mainstream health practitioners, there are several
illnesses and beliefs in the Haitian culture that do not have equivalents
in mainstream medicine:
1. Perdition
Perdition is an illness where a woman has a fetus trapped in her womb,
often for many years, before eventually delivering the child. Perdition is
believed to be the result of natural causes such as walking barefoot on wet
ground or carrying too heavy a load, although it can also be the result of
a spell being cast on the unborn child's family. It is believed that at
some time during pregnancy some force effects the child and its development
is reversed until it is a tiny speck. The fetus still remains in the womb
and the woman is considered pregnant. A woman who is in perdition will
menstruate, although the flow will be less than usual. Haitian women who
believe in perdition will insist that this is not a miscarriage, which they
recognize as something different from perdition. As long as the woman is
in perdition, the child remains inside her. When she clears up her
problem, the same child starts growing again and will emerge nine months
later, none the worse for the months or years spent dormant in the mother's
womb. A female focus group participant asserted, with no hesitation and
with no sense of inappropriateness, that she spent eight years in her
mother's womb before being born. Her legal father was her mother's former
husband, who had impregnated her mother and then left her eight years
earlier. Other focus group participants knew of similar circumstances.
The idea of perdition is apparently deeply rooted in Haitian culture and
serves several purposes:
a) It reduces the stigma of being barren or sterile; a woman
in perdition is not infertile; her pregnancy is "on hold."
A woman in perdition has a higher status than a non-pregnant
woman;
b) A woman in perdition is more secure in her conjugal union.
Sterility is grounds for dissolving a union; a woman in
perdition is carrying a man's child and he is responsible to
her.
A Haitian woman who states that she has been pregnant for more than
the usual number of months is not biologically naive or suffering from
psychotic delusions. Rather. she is simply using a common, culturally
acceptable explanation for her condition. It should not be assumed that
she needs to see a psychiatrist.
1 1 1-3
2. Blood Classification
Blood plays a central part in the Haitian concept of illness, which
may explain why some Haitians are suspicious of a lot of blood tests.
Haitians may feel that losing blood will make them weak or that the blood
could be used for voodoo purposes. One focus group participant implied
that doctors who order a lot of blood tests may be selling the blood for
profit. The blood is believed to be the main determinant of whether a
particular person's body is hot, cold or somewhere in between (see section
below on hot/cold classification system). Table 1 describes the various
types of blood and their causes and/or effects; information for this table
is taken from Laguerre (1981).
These concepts of blood also influence the choice of a method of birth
control. Scott (1975) reports that Haitian women, as well as women from
other cultures, are reluctant to use a method of birth control that effects
menstrual flow. The IUD is an example as it often increases the flow, and
the Pill because it often decreases the flow. Menstruation is viewed as a
natural, healthy event and changes in the menstrual flow may indicate that
something is wrong.
3. Beliefs about Bad Blood. Rising Blood, and Insanity
Bad blood, which is usually the result of blood mixing with some other
substance, is a commonly believed cause of a variety of illnesses. A
person who becomes violently angry is said to "make bad blood." It is
believed that when a person loses his or her temper seriously, blood will
rise up into a person's brain, perhaps causing insanity if the attack is
sufficiently strong. Any violent emotion — anger, grief (e.g., at the news
of a sudden death of a loved one), or sudden terror — is believed to cause
blood to rise to the head and to be capable of damaging one's blood for an
indeterminate period of time. This pattern of damaged blood appears to be
especially frequent and of especially deleterious consequences in females.
Many folk remedies applied during fits of violent emotion (e.g. , tying the
head of the patient with a kerchief, pouring coffee on the crown of the
head) have as their stated function the return of the blood to its normal
position and the prevention of its spoiling.
A patient may feel a non-specific illness which she tries to explain
to a physician. It may very well be that the patient assumes that this
illness may be related to a spell of anger, grief, or fear which she had in
the past and which reduced the quality of her blood.
4. "Rising Milk." "Spoiled Milk." and "Milk Mixed with Blood"
Female milk is another substance believed vulnerable to displacement,
improper mingling, and permanent, irreversible spoiling. There are
particularly strong cultural injunctions against causing a lactating woman
to lose her temper as she may harm either herself or her child. At worst,
her milk may physically rise to her head and enter her brain, causing
violent behavior and perhaps insanity. Somewhat milder in its consequences
for the woman herself but perhaps not for her child is the danger that
the milk may become mixed with the woman's blood and be permanently spoiled
III-4
TABLE 1
HAITIAN CLASSIFICATIONS
AND THEIR CAUSES
Blood Condition
Sancho: hot blood
San
fret:
San
cle:
San
febl:
San
epe:
San
io-n:
San
noa:
San
sal:
San
eate:
cold blood
thin blood
weak blood
thick blood
yellow blood
dark blood
dirty blood
spoiled blood
OF BLOOD CONDITIONS
AND/OR EFFECT
Cause and/or Effect
high fever
nervousness
intellectual activity
sleep
physical exercise
after childbirth
malaria
quiet rest
pallor
physical weakness
mental weakness
fright
itching
bile flowing in blood
patient will soon die of an
incurable disease
venereal disease
skin eruptions
fright
venereal disease
skin eruptions
III-5
for the duration of that nursing cycle. It is believed that the spoiled
milk would poison the child; a child is immediately weaned if the mother
has had her "milk spoiled."
Just as perdition (mentioned above) serves explanatory purposes for
members of the culture, so also does the idea of "spoiled milk." In its
earlier form in rural Haiti, this belief appears to serve as the rationale
for giving the lactating woman 12 to 18 months of rest and special
treatment. Spoiled milk also, quite conveniently, permits the mother to
resume her economic activities without falling under public censure of
being an irresponsible mother.
5. The Wandering Womb
The concept of a displaced organ causing problems is seen very clearly
in the beliefs surrounding a woman's immediate postpartum experiences.
Interview findings indicated the continued existence among immigrants in
New York and New Jersey of a belief that has been observed in Haiti
concerning the behavior of a womb from which a child has just been born.
A physical and emotional attachment is believed to exist between the
womb and the child. When the child exits the womb, the womb senses a
sudden, radical, violent emptiness. In a panic the womb begins moving
frantically all over the woman's body searching desperately for the
occupant that has suddenly departed. The womb is believed on some
occasions to make its way into one of the limbs of the new mother.
The weakness, dizziness, confusion, and disorientation that many women
feel after childbirth is generally attributed to the effect of a displaced
womb that has moved about looking for the child. The situation can be
remedied by the massaging of a skilled granny midwife. This massaging
serves the dual function of, first, locating the position of the displaced
womb and, second, gently easing it back into its proper position.
Also of critical importance to the placating of the frantic womb is
filling it with rich food. The one occasion on which a woman is pampered
with abundant food in rural Haiti — including even the killing of a family
animal (usually reserved only for cash sale in the market) — is on the four
or five days immediately following delivery. The midwife will have
restored the frantically searching womb to its rightful position. But it
is the responsibility of the woman's husband and family to remove the empty
feeling of the womb by filling it with food.
6. Gas
Gas is also important as a cause of illness, particularly pain and
anemia. Gas can enter the body through the ears and mouth and lead to pain
in the head. stomach, legs (rheumatism), back, and shoulder. Gas may be
caused by eating leftovers. A woman who has just given birth may wear a
tight belt around her waist to keep gas from entering her body. Gas may be
treated with tea made from garlic, mint and cloves or by eating plantain or
corn.
III-6
7. Hot-Cold Theory of Disease
The hot-cold classification system plays a role in the Haitian system
of health beliefs and behaviors, although it is unclear how strictly or how
frequently the system is applied by Haitians living in the New York/New
Jersey area. Essentially, the hot-cold theory divides illnesses,
medications, and foods into hot and cold categories. Good health is the
result of maintaining a proper balance between hot and cold states. The
designation of "hot" or "cold" is not related to the temperature of the
food or medication although temperature may be related to beliefs about how
a person develops a particular illness. There may also be individual
variation in the classification system, depending on how the person
responds to specific foods or medications.
In the Haitian hot-cold system, classification of body states is
related to sex and reproduction. For example, females are always "warmer"
than males and pregnant women or women who have recently given birth are
"warmer" than other women. The first three months postpartum is the
"hottest" state and may be a period of relatively severe dietary
restrictions; only cold or cool foods (such as certain fruits, cashew
nuts, and cassava bread) may be eaten during this period.
One researcher (Weidman, 1978) has found that some Haitian mothers
will give a type of milk of magnesia (classified as a "cold" remedy) to
cure diarrhea with fever (classified as a "hot disease"). This treatment
in many cases, will worsen the child's illness. In addition, Haitian
mothers may resist giving children with diarrhea an oral electrolyte
solution alone because they may feel that the baby will die without food.
B. USE OF HOME REMEDIES AND TRADITIONAL HEALING
Our research strongly suggests that Haitians who use traditional
healers and remedies are likely to simultaneously seek out the advice of
traditional and mainstream providers and to use traditional and mainstream
remedies together. Therefore, it is important that mainstream provider be
aware of the types of providers and remedies their patients may be
using.
1 . Home Remedies
Discussions with Haitian patients and staff from New York/New Jersey
area health centers indicate that leaves, herbs and oils are commonly used
for self treatment and for treatment by traditional healing experts.
Leaves may be boiled, used for a bath, or placed directly on the injured
areas. Oils may be used for massage. Traditional remedies may be
purchased in botanicas or brought directly from Haiti. Some examples of
traditional home remedies which were mentioned in our discussion groups
follow:
a) asorousi: a tea boiled from leaves that will restore
person's appetite.
III-7
b) fev korosol: a child's head is bathed in this to cure
insomnia.
c) a variety of leaves are used for gas or if a child's
stomach is swollen.
d) loks (purgatives) may be given to a baby as a first food to
expel the meconium. Castor oil is frequently used; it is
stirred into hot water with salt and sugar. This mixture
is given to the baby once a day for three days. The lok
works when the mother sees green stains; this means that
the child is cleaned out.
e) warm oils are used in combination with massage to solve a
number of problems from aching or sprained bones to
displaced organs.
Table 2, based on information taken from Clerisme (197 9) includes
substances that are used in Haitian folk medicine. There appears to be a
fairly consistent use of the plants based on their perceived healing
properties.
2. Traditional Healers
There are four basic types of traditional healers in Haiti:
a) Docteur-feuilles or bocars: leaf doctors who treat patients
with medicinal plants, herbs and roots, occasionally along
with mystical ritual. Leaf doctors are generally called on
to perform certain standard services such as bone setting
and burn treatment. One of his major theoretical tools is
the concept of the "foulay" — an internal blockage of blood
that forms clots which the leaf doctor can dissolve by a
combination of massage and herbal medicines. Droquistis
also fit into this category; they bottle and sell potions.
b) Houngans/mambo s : voodoo priests/priestesses who practice a
combination of magic and religion. Voodoo is a complex of
religious beliefs, practices and specialists which assumes
the existence and intervention of a number of spirits in
human affairs. The major focus of voodoo in rural Haiti is
the healing of illness. In the United States, the major
focus of voodoo may be to make someone ill or "work with the
left hand." Voodoo is, in effect, a folk medical system
which differs from other systems in that the illness-causing
agents are believed to be conscious, active spirits rather
than natural forces.
c) Sages-femmes/matrones/fam sai: lay midwives, wise women,
usually women without medical training, who perform
deliveries and other work with women.
d) Piquristes: people who give shots and apply dressings.
These healers usually have some technical experience and
III-8
TABLE 2
PLANTS, LEAVES. ROOTS, BARK AND FLOWERS CONSIDERED
THERAPEUTIC IN TRADITIONAL HAITIAN CULTURE
HAITIAN
ENGLISH NAME
BOTANICAL NAME
EFFICACY
Acajou
Mahogany
Swietemia Mahogani
Bark, enriches
blood.
Bambou
Bamboo
Bambussa vulgaris
vel Arundian
An infusion of
the leaves is
used to control
coughs and to
cure colds.
Bo is de Chene
Oak tree
Catapa longissimue
Callebasse
Marronne
Wild calabash Cressentia Cujete
An infusion of
the leaves is
used to cure
cramps and fever.
A syrup made of
the calabash pulp
is used to melt the
"deposits" in
"foulaille." It
is also used to
prevent "foulaille"
after a contusion.
Avocat Marron
Cresson Marron
Wild avocado
Wild
watercress
Lepidian
Virginicum
An infusion of the
leaves that relieves
hypertension.
A tea made from
these along with
the leaves of
eayemite and papaya
stimulate breast
milk of a nursing
mother.
Graine de
Cotonnier Violet
Cotton seed
Gosypium
Roasted cotton seeds
prepared like coffee
stimulate breast milk
Pistache Marron
Wild peanut
Polygala
forniculata
An infusion made
of the leaves
combined with those
of laiteron is used
to treat grippe.
Alone, it is said
to prevent
hypertension.
I II- 9
TABLE 2 (continued)
PLANTS. LEAVES. ROOTS. BARK AND FLOWERS CONSIDERED THERAPEUTIC
HAITIAN
Citronelle
ENGLISH NAME
Citronnella
BOTANICAL NAME
Cymbopoyam
nardus
Thym Grande s
Feuilles
Thyme
Thymus vulgaria
Saf ran
Saffron
Curcuma longa
EFFICACY
Infusions of
citronnella leaves
are taken to cure
gas or stomach
cramps. The leaves
are also used in
soothing baths.
An infusion made
from 2-3 thyme leaves
is good for all sorts
of pain, fever,
chills, grippe or
cramps. To relieve
a headache, several
leaves are inhaled.
A small piece of
the root soaked in
a glass of cold
water is used in
cases of fever,
particularly when
accompanied by
jaundice.
111-10
tend to be the youngest of the traditional healers. It is
interesting to note that Haitian focus group participants
expressed a preference for injections and are suspicious of
all the pills that are prescribed in the United States.
They place a great deal of confidence in vitamins that are
given by injection.
There is some overlap in categories; many of the houngans, mambos,
and sage-f emmes also work as docteurs-f euilles. In Haiti, the healers are
respected and loved in their communities yet tend to be modest about their
role in influencing the members of their community. Most are illiterate,
over forty and poor, although some of the healers who specialize in magic
may be quite wealthy in comparison with the other members of their
community.
Docteurs-f euilles and matrones generally learn their trade from
relatives who pass the practice on to them. Most of the training is
observational and consists of hands-on experience, although recipes are
also passed along. Piquristes may receive training in missions or modern
medical facilities, which increases their credibility and increases the
probability that they will refer patients with serious illnesses or wounds
to these facilities. Houngans start their practice by buying loas or
spirits or by being claimed by the loas of an ancestor. The process of
becoming a houngan is long and complicated and involves a succession of
ritualistic ceremonies. Remedies are generally given to the houngans by
the spirits although some houngans learn the recipes from their relatives
with whom they apprentice. In such cases, the spirit of the relative is
passed on to the new houngan in a ceremony after the relative's death.
As mentioned above, the Haitian patients and staff members who
participated in our discussion groups expressed some knowledge of voodoo or
witchcraft but said that it was not widely practiced in their neighborhoods
or among their friends and relatives. However, another type of
traditional healer — the lay midwife or wise woman — was discussed to a
significant degree by the participants. Although the participants were
somewhat reluctant to say directly that there are unlicensed Haitian
midwives who perform services in the New York/New Jersey area, it became
clear from what was said and the way it was said that if a lay midwife is
needed, she can be easily found. Midwives are highly regarded; they are
believed to possess a significant amount of knowledge and skills . They
are particularly skilled in areas related to childbirth, massage and the
preparation of herbal remedies. Specific examples of lay midwifery skills
are listed below:
a) They can tell a new mother when her milk and blood have
mixed and can give a special drink and ointment to solve the
problem.
b) They understand perdition and under certain circumstances
can release the child.
c) A Haitian belief is that after birth a woman's womb can be
dislocated which can give the woman swollen feet, among
other problems; a midwife can solve this problem.
III-ll
d) Lay midwives are experts at massage for both diagnostic and
healing purposes. Their fingers may probe deeply to receive
signals about harmful gaps between two bones that should be
joined, the absence of an organ that should be in a
particular place, or the presence of an organ in one place
when it should be in another. Once problems have been
identified, massage is used to nudge the organs or bones
back into place.
e) Lay midwives may play an important role in the immediate
post-partum period. Haitian tradition prescribes a long
recovery period for a woman who has just delivered a baby.
She may not be allowed to leave her house or undertake any
activities for several weeks or months. The midwife may
make special teas to clean out the woman's stomach, prepare
special baths and massage the woman's body with special oils
so that it returns more quickly to its pre-pregnancy state.
Of particular significance to non-Haitian mainstream providers serving
Haitian patients are the norms governing what is considered appropriate
behavior on the part of Haitian folk healers, including lay midwives and
leaf doctors. There is not an automatic assumption that the traditional
healer is competent; it is known that some healers are more competent than
others. It is also recognized that even competent healers may not be able
to find the cause of a particular illness, although rarely will a healer
admit his or her inability to diagnose and cure a problem. A healer is
expected to appear confident of his or her abilities at all times.
One common "test" which patients apply to their healers in Haiti and
other parts of the Caribbean is to determine if the healer is able to
diagnose the problem with as little help from the patient as possible. The
ideal diagnostic procedure is for the healer to examine the patient with
no questions asked and to describe to the patient, after this examination,
exactly what pain or illness motivated this visit by the patient, and what
the underlying cause of this pain is.
Conversely, a folk healer may be suspected of quackery if he begins
soliciting detailed information from the patient concerning symptoms
(although questions concerning diet seem to be appropriate). The patient
may feel that he is "doing the doctor's job for him."
Healers have several standard examination procedures. Mention has
already been made of the massaging techniques of the midwife. These
techniques have also been mastered by competent leaf doctors. In addition,
a skillful leaf doctor is supposed to be able to examine a person's
fingernails. There is a folk understanding of the human body by which all
nerves running through the body are believed to have terminals in the ten
fingernails. By examining irregularities in the texture or coloring of the
fingernails, the skillful leaf doctor will be able to identify, for
example, where a "foulay" (blood blockage) may be affecting the patient's
body. Or a leaf doctor should be able to look carefully at a patient's
eyes and detect signs of "febless" (generalized weakness). All of this is
ideally done with as little questioning of the patient as possible.
111-12
C. ATTITUDES TOWARD AND USE OF MAINSTREAM HEALTH CARE PROVIDERS
As can be seen from the preceding, Haitian patients expect certain
behaviors from healers in the process of diagnosing an illness. The
confidence-inspiring healer is one who receives the patient with several
moments of conversation about the patient's life in general and who quickly
proceeds to a straightforward, confident, hands-on examination of the
patient. an examination that proceeds with minimum of suspicion-evoking
questioning by the healer. It is the healer, not the patient, who is
supposed to say what is wrong.
Haitian patients may know in theory that modern physicians "are
supposed to" proceed differently when they are diagnosing a patient. But
comments that came out in several interviews indicate that at least some
patients entertain misgivings about the competence of a doctor whose
physical examination of a patient is cursory and whose main diagnostic tool
seems to be a long series of questions posed to the patient, particularly
questions about a patient's family history. A folk healer who makes
diagnoses in this manner might be dismissed as a fake.
Several comments in the interviews indicate that Haitian (and
Hispanic) physicians practicing in the islands and in New York and New
Jersey recognize these expectations and adapt their own behavior
accordingly. Some are reported to be willing to prescribe traditional
remedies if they seem to be appropriate and even to send the patient to a
traditional healer if he, the physician, suspects a traditional malady.
But even those who do not go this far, or who may even denounce folk
healers as charlatans, apparently do at least adopt some of the
confidence- inspiring diagnostic style of these popular folk healers.
As mentioned in the previous section, Haitian patients may be
simultaneously using traditional and mainstream health practitioners. As a
partial explanation for the duality, the discussion group participants felt
that most American, mainstream health care providers do not know about,
understand, or accept Haitian theories of illness and traditional healing
practices. In fact, many Haitians think that American-trained providers
consider all Haitians crazy, think they imagine illnesses. As a result of
this perception, Haitians may delay seeking care, may hide their use of
traditional healing substances and practices from the mainstream providers,
and may simultaneously seek the advice of a number of providers.
Group participants also felt that only traditional healers have the
knowledge and the skills to treat particular illnesses so that it doesn't
make sense to take these complaints to a mainstream provider.
Communication can break down between non-Haitian providers and Haitian
patients both because of language barriers and because of their very
different ideas about the existence and causes of particular illnesses. As
with each of the cultural groups we included in this study, Haitian
participants respected and appreciated mainstream providers who made an
effort to learn about and respect their cultural beliefs and practices. It
is not necessary for the providers to agree with the beliefs and practices,
but it is important that they not criticize them. Similarly, providers who
make an attempt to speak a few words of the patient's language are highly
regarded. It is not as important that the providers be fluent in the
language, -just that they try.
111-13
D. IMPLICATIONS FOR NON-HAITIAN PROVIDERS TREATING HAITIAN PATIENTS OR
WORKING WITH HAITIAN STAFF
As previously stated, it would be inappropriate for a non-Haitian NHSC
provider working with a Haitian population to assume that all, most, or
even the majority of his or her Haitian patients' health beliefs and
practices are described in the preceding pages. With this point in mind,
and recognizing that each provider has an individual style of practice, the
following list includes examples of situations that might arise when
providing health care services to Haitian patients.
1. As with any cultural group, Haitians have a coherent system of
health beliefs and practices. Without having to accept those
beliefs as "true," mainstream providers should attempt to
recognize and respect their existence and their influence on a
Haitian patient's successful use of the mainstream health care
system. A person who uses and responds to the mainstream health
care system based on his or her cultural beliefs may behave in a
way that is not understandable or appropriate to the mainstream
provider. It is critical that a mainstream provider recognize an
inappropriate "cultural fit" for what it is and not interpret it
as craziness, stubbornness, or stupidity on the part of the
patient.
2. Spiritual causes and cures of illness appear to be a sensitive
issue among Haitians living in the New York/New Jersey area.
Although most Haitians we spoke with are familiar with the basics
of voodoo, few openly accept or practice it. Haitian patients and
staff may be very sensitive to the fact that American health
providers think all Haitians believe in voodoo and are "a little
bit crazy." Providers should, of course, avoid this
generalization; in most cases, it would be best if the health
provider did not raise the issue at all unless the patient
indicates some belief in voodoo.
3. A Haitian woman who states that she has been pregnant for longer
than the normal period may be expressing a belief in perdition.
This will probably not come up directly as most of the women will
recognize that American providers do not know about or accept the
idea of perdition.
4. Blood plays a central role in the Haitian health belief system.
When ordering blood tests, the provider should explain why the
test is being given. Also, Haitian women may be reluctant to use
either the Pill or the IUD because of the effect of these methods
on blood flow.
5. A variety of traditional practices may influence a woman's
treatment of herself and her child in the immediate post-partum
period. Purgatives are commonly given to newborns and the
mainstream provider may want to spend additional time explaining
the danger of this practice or discussing substances that could be
used instead of castor oil.
6. The provider should realize that a woman who stops breastfeeding
may do so because she believes that her blood has mixed with her
111-14
milk and spoiled it. A mainstream provider may not be able to
reassure the woman to her satisfaction, but knowing the possible
reason may help the woman and the provider communicate better.
7. A new mother may resent the suggestion that she resume normal
activity soon after birth; Haitian tradition prescribes a long
recovery period. Also, a woman may believe that her womb has been
displaced, which may affect how the provider chooses to conduct
the post-partum exam.
8. Haitian patients may be seeing a variety of practitioners for the
same problem. NHSC providers may want to ask patients about other
medicines that they've tried to make sure that their prescription
is not contraindicated.
9. Teas are commonly used as home remedies. Discussions with Haitian
staff members might provide useful information about home remedies
that are potentially dangerous. More generally, staff can be
excellent resources for the provider and their opinions and
knowledge should be solicited.
10. Traditional Haitian healers tend to rely more on physical exams
and less on questioning than American-trained mainstream
providers. In order to make their Haitian patients more
comfortable and less suspicious, providers may want to emphasize
the exam more and explain why particular questions are being
asked. At the least, the provider should understand that
hostility toward questioning may be culturally-based.
11. Haitians may prefer injections to pills and may place a high value
on vitamin injections.
12. As with each of the groups studied, Haitians tend to appreciate
and respect a provider who makes the effort to learn a few words
of Haitian Creole and something about Haitian traditional health
beliefs and practices.
13. Providers should be aware that infants may be given fatty, salty
table foods at a very early age.
14. Pregnant women may need to have their weight gain closely
monitored; special nutrition counseling might be necessary.
15. Obese, hypertensive, or diabetic Haitians are likely to resist
making changes in their diets.
1 11-15
BIBLIOGRAPHY
HAITIAN HEALTH BELIEFS AND PRACTICES
Buchanan, S.H. (1982). Language and Identity: Haitians in New York City.
International Migration Review 13, No. 2.
Chen, Kwan-Hwa and Gerald F. Murray (1976). Truths and Untruths in Village
Haiti: An Experiment in Third World Survey Research. In, Culture,
Natality and Family Planning. ed. Marshall. Carolina Population
Center, University of North Carolina.
Clerisme, Calinte (1979). Recherches sur la Medecine Traditionnelle.
Division d'Hygience Familiale, Department de la Sante, Publique et de
la Population.
Coreil, Jeannine (1983). Allocation of Family Resources for Health Care in
Rural Haiti. Social Science and Medicine. 17, No. 11.
Dempsey, P. A. and T. Geese (1983). The Childbearing Haitian Refugee,
Cultural Applications to Clinical Nursing. Public Health Reports 98,
No. 3 (May/ June).
Jelliffe, D.B. and E.P. Patricia Jelliffe (1960). Prevalence of Protein
Calorie Malnutrition in Haitian Preschool Children. American Journal
of Public Health.
Laguere, Michel S. (1979). The Haitian Niche in New York City. Migration
Today 7.
Laguerre, Michel S. (197 9). Haitian Americans, Ethnicity and Medical
Care, ed. Alan Harwood, Cambridge, Massachusetts: Harvard University
Press.
Leonidas, Jean Robert (1982). Depression a la Haitian. New York State
Journal of Medicine. (April).
Mathewson, Marie A. (1975). Is Crazy Anglo Crazy Haitian? Psychiatric
Annals 5 (8).
Murray, Gerald F. (1976). Women in Perdition: Ritual Fertility Control
in Haiti in, Culture. Natality and Family Planning. ed Marshall.
Carolina Population Center, University of North Carolina.
Scott, Clarissa S. (1974). Health and Healing Practices Among Five Ethnic
Groups in Miami, Florida. Public Health Reports 89, No. 6.
Scott, Clarissa S. (1975). The Relationship Between Beliefs about the
Menstrual Cycle and Choice of Fertility Regulating Methods Within Five
Ethnic Groups. International Journal of Gynecology and Obstetrics.
13. ~~
Stepick, Alex, et. al. (1982). Haitians in Miami, An Assessment of their
Background and Potential. Dialogue #12, Occasional Papers Series.
Latin American and Caribbean Center, Florida International University.
111-16
(Bibliography/Haitian cont.)
Weidman, Hazel H. (1978). Miami Health Ecology Project Report: A Statement
on Ethnicity and Health. Department of Psychiatry, University of
Miami School of Medicine (Mimeo).
Weise, H. Jean C. (1976). Maternal Nutrition and Traditional Food Behavior
in Haiti. Human Organization 35.
Weniger, B. , et.al. (1982). Plants of Haiti Used as Antif ertility Agents.
Journal Ethnopharmacology 6, No.l (July).
IV. LOW INCOME BLACK BOOKLET
IV. COMMON HEALTH BELIEFS AND PRACTICES OF LOW INCOME BLACKS
LIVING IN THE NEW YORK/NEW JERSEY AREA
Low income Blacks compose a heterogenous, ever-changing cultural group
that has slowly been integrating into the mainstream culture. Of the three
ethnic groups studied for this project (Haitians, Puerto Ricans and low
income Blacks), Blacks appeared to have health beliefs least divergent from
mainstream medical practice. This is not surprising since, of the three
groups, they have been a part of the American culture for the longest time
and do not have the language barriers experienced by the other two.
Although these facts make it more difficult to identify their unique and
important health care characteristics, many Blacks do hold traditional
health beliefs and utilize folk healing practices quite different from
modern medical practice.
The information on low income Blacks in this booklet generally refers
to those who are native Americans or who have lived almost their entire
lives in the U.S. These are distinct from, for example, Haitians who are
Black and also of low income. There is a paucity of research on the health
beliefs of Blacks and much of what has been conducted was done in the
south, southwest and midwest and it is uncertain to what extent the
findings from these studies can be generalized to urban, eastern Blacks.
One Black staff person of a Region II NHSC site stated that "a lot of times
we don't understand what the patients are saying either. Southern Blacks
have an altogether different culture from northern Blacks." Because
physicians in a TTISC site may see Black patients originating from many
regions of the U.S. and the Caribbean, and because these patients will
have health beliefs varying not only by region but also by individual
adherence to any one belief, it is important that physicians not stereotype
Blacks by assuming that all Blacks hold any particular belief.
A. CONCEPTS OF DISEASE AND ILLNESS
There are a wide range of traditional health beliefs and medical care
practices among low income Blacks. For many, ideas about illness and its
causes result from a combination of folk, popular and biomedical ideas and
each particular geographical or social subgroup of low income Blacks has
its own special mix (Jackson. 1981). A large number have holistic
viewpoints and make no distinction between science and religion or mind and
body in their concepts about health and illness (Snow, 1978). Often
illness is considered to be the result of conflicts between good and evil
or between natural and unnatural forces. Events in life are believed to
affect all aspects of a person's life including their job, family life and
health.
In this traditional system, the cause of the illness is the most
important factor — not how that cause is expressed (symptoms). Many Blacks
believe that the causes of illnesses are of two types: natural or
unnatural. The decision about which type of illness a person has is
pivotal because it has implications for the type of care initially sought.
Depending on the believed cause, an individual may seek out a variety of
IV-2
cures from home treatment to folk healers to mainstream practitioners. An
individual may interpret the same symptoms differently depending on the
risks to which he or she has been exposed and on his or her beliefs
surrounding the illness. This interpretation may change with further
evaluation. In addition, it is believed that illnesses can be "cured" by
spontaneous expulsion from the body en masse (Snow, 1974), therefore,
individuals may not seek care or may use this for an explanation of its
cure.
Women, the very young, and the very old are believed to be more
susceptible to illness. For women, fairly specific techniques for personal
care are defined which are conducive to good health. For example,
menstruating women should never go swimming, they should never go to bed on
a full stomach and hair should be shampooed at a defined frequency
(Jackson, 1981). Black women may also reject contraceptive methods that
alter the monthly menstrual flow (such as the IUD and the Pill) because a
change in this may be viewed as a threat to health and well-being (Scott,
1975). There are also many taboos associated with pregnancy. The thoughts
and cravings of a mother during pregnancy are believed to affect the health
and physical appearance of the baby.
1 . Natural Causes of Illnesses
Natural causes of illness are those attributable to either the natural
environment or to God's punishment (Snow, 1978). Most illnesses may
initially be seen as the result of acting foolishly by not following the
basic tenets of good health and may be treated by a variety of home
remedies, many of them herbal. It is the individual's responsibility to
maintain his or her health by following a moderate lifestyle, protecting
him or herself against excessive heat or cold, eating a healthy diet, and
keeping his or her system clean. (Sometimes the latter necessitates taking
laxatives fairly regularly to prevent "impurities" from building up.)
Natural phenomena such as the phases of the moon and the seasons are also
believed to affect the body (Snow, 1974). For example, some Blacks believe
that hypertension is affected by changes in the weather or small changes in
diet: therefore, to them, it may not make sense to take dramatic action to
cure hypertension.
Some natural illnesses are believed to be caused by a failure to
"know, love, and serve God" as represented by going to church and praying.
Long term illnesses are often believed to be the result of God taking
action to give the person or family time to contemplate their weaknesses.
Mental retardation and strokes leading to paralyses are examples (Snow,
1978). For these types of illnesses, the individual or family will be
cured only after making peace with God: recognizing the sin, feeling
remorse for having committed it, vowing to improve and taking action to
improve.
2. Unnatural Causes of Illness
"Unnatural" causes of illness are those due to forces such as
"worriation, " stress from everyday living, evil influences, or sorcery. In
some instances there is a fine line between the designation of a natural or
IV-3
unnatural cause. Illnesses resulting from "worry", "nervousness", or
"stress" are classified as "unnatural" if the person is worrying about
something over which he/she has no control. For example, many urban Blacks
believe that stress (especially stress resulting from racism) causes
hypertension (Jackson, 1981). Another common belief is that diabetes is
the result of "worriation, " a belief with some basis in medical fact.
An unnatural illness can also result from a natural illness if it was
the result of God's punishment. This can happen if the person does not
mend his ways, make peace with God and thereby prevent the removal of God's
protection. This removal leaves the person at the mercy of the devil or
other evil influences.
Some low income Blacks believe that an illness can be caused by
sorcery in the form of voodoo, hoodoo, rootwork, hexing, or witchcraft.
These systems are largely based on the idea that associates, especially
friends, neighbors, or relatives, can exploit and control you by using
information about you to fix a spell. Usually an intermediary who has
contact with the spirits is used to cast these spells. Envy often plays an
important role in them: envy of success, beauty, or good fortune in the
areas of love, business or politics (Wintrob, 1973) . A spell or hex may be
put on an individual either to make him ill or to cause him to act in a
certain way. For example, a husband who does not want his wife to be
unfaithful to him may place a spell on her to keep her faithful. Potions
for love purposes are common in some inner city neighborhoods.
Spells are often cast by making a powder from something that belongs
to or was part of the individual being "hexed" (e.g. clothing, hair, nail
clippings, excreta, or soil that the person las walked over.) The powder is
placed in the victim's food or drink (Snow, 1974). After eating or
drinking the altered food the individual responds by having stomach cramps,
vomiting, diarrhea, intense tremors or unusual behavior (Wintrob, 197 3).
Because "poisoning" food is believed to be a common mode of casting a
spell, gastrointestinal problems may be viewed as the result of a hex.
Spells are not placed lightly because the person placing the spell is
endangering himself due to the possibility that the person "hexed" can find
a more powerful intermediary and turn the situation around. Thus, spells
are usually actions of last resort after other means of solving the problem
have been attempted (Wintrob, 1973).
Unusual symptoms (i.e. symptoms no one has ever seen before or ones a
physician expects to be able to cure but cannot) are likely to be viewed as
the result of witchcraft. Losing weight while continuing to eat normal
amounts is seen as a particularly ominous sign that may mean a spell has
been cast. Unnatural illnesses are often viewed as the result of animals
or reptiles (commonly including snakes, lizards, spiders, toads and frogs)
being lodged somewhere in the body. They are assumed to be introduced into
the body by putting either animal eggs or powder made from the animal into
the person's food. The eggs hatch or the powder is reconstituted once
inside the body.
Normal symptoms might be seen as the result of witchcraft if the
individual has been warned that he will have the symptom or if the
individual has a guilty conscience. For example, a spouse who feels guilty
IV-4
about being involved in an extramarital affair is more likely to believe
that symptoms are the result of a spell than a spouse who does not feel
guilty (Snow, 197 8).
Changes in behavior may also be believed to be the result of a spell.
Depression, crazy behavior, anorexia, and inability to perform the usual
tasks of life may all be seen as the result of a hex. There is evidence
that hypnosis may be an appropriate method to use with patients who have
the above mentioned symptoms and believe them to be the results of
witchcraft (Snell, 1976). Folk healers may be particularly sought out and
effective as psychotherapists because they have more time for the patient
and more understanding of the patient's problems as they relate to his
family life and social conditions (Jackson, 1981).
Research findings are not consistent about the percentage of low
income Blacks that believe in sorcery or related concepts and seek out care
from these types of providers. However, regardless of the exact
percentage, it is evident that these beliefs have influenced the culture's
health concepts to some degree. As a result, "unnatural" illnesses are
particularly frightening because they are seen as removed from God's
influence and the healing abilities of friends, family and mainstream
practitioners.
3. Perceptions About Cancer
In a study of Black Americans' attitudes and knowledge about cancer
(ACS, 1981) several interesting findings were discovered about Blacks'
perceptions and behaviors with respect to cancer. Blacks may think that,
among illnesses, cancer is the main preoccupation of white people, and that
high blood pressure and sickle cell anemia are primary preoccupations of
Black people. Blacks more often believed cancer to be fatal and treatments
to be less effective than is actually the case. Futhermore, few Blacks
could name cancer's warning signals and were less likely to seek medical
care if they experienced any of these symptoms. They were, however, very
interested in receiving educational programs about cancer prevention.
About half of the Blacks studied believed that "surgery can expose
cancer to the air" and cause it to spread. Also, approximately one-fourth
said they would "feel uncomfortable" working next to someone who had
cancer.
B. USE OF HOME REMEDIES AND TRADITIONAL HEALING PRACTICES
Low income Blacks use a wide variety of home remedies. traditional
healing practices and modern over-the-counter drugs. As is characteristic
of the majority of the population, they seek advice first from friends and
relatives, try home remedies and then if the illness is serious enough and
still remains, they may seek mainstream medical care.
IV- 5
1. Home Remedies
Members of low income Black patient groups of NHSC sites in Region II
revealed significant experimentation with and use of home remedies. Often,
different treatments for the same illness were given by various members of
the groups. These remedies, summarized in Table 2, may be of particular
interest to NHSC physicians serving this Region.
As is evident from the above table, Black patients in Region II
display a significant knowledge and use of home remedies. Herb teas were
mentioned several times and are apparently used for many types of ailments.
Also mentioned frequently was the solicitation and use of advice from
health food stores. Several patients considered the personnel of these
stores to be very knowledgeable about natural and effective treatments for
illnesses. One Southern Black stated that castor oil was used for
"everything" in the south. Also, Blacks may be suspicious of a lot of
blood tests or feel that they are more harmful then beneficial. Some of
the Blacks in the focus groups terminated treatment after being given
several blood tests.
Some of the home remedies found among low income Blacks in Louisiana
include wearing garlic around the neck, for tuberculosis; drinking a tea
made of sheep manure, for whooping cough; wearing a bag of asafetilda
around the neck, for worms, and eating horehound root for diabetes (Webb,
1971). These treatments may not be directly transferable to urban, eastern
Blacks but they give some idea of the types of home remedies that may be
used.
Other harmful uses of home remedies found by researchers have included
laxative abuse and oral use of kerosene, turpentine, moth balls and carbon
tetrachloride (Snow, 1974).
2. Use Of Traditional Healers
A percentage of low income Blacks use traditional healers.
Advertisements by these healers can commonly be found in low income Black
communities. It is uncertain, however, how prevalent this use is and how
it varies by geographic region. A great deal of secrecy surrounds the use
of them so the distinction in the type of problems each deals with are not
clear to the outsider. Some use roots, herbs, and patent medicines and
some use massage with special oils. Others use candles, charms and
amulets. Often healing takes place as part of a religious ceremony.
Frequently, healers provide a substance that leads to some physical symptom
(such as vomiting) which is an indication that the cure is working. Folk
healers are confident in their ability to heal and unlike many mainstream
practitioners are usually available •immediately and at all times of the
night and day, and can often work cures through the mail or over the phone.
They are also of the same economic class and cultural background as the
patient and therefore better understand the patient's concerns. Their
power to cure is considered to be given by God.
Only certain individuals are believed capable of enacting or removing
spells; these persons are intermediaries who have special knowledge of and
relationship with supernatural forces. They are called by many names
IV-6
TABLE 1
HOME REMEDIES USED BY LOW INCOME BLACK PATIENTS OF NHSC
SITES IN THE NEW YORK AND NEW JERSEY AREA
Illness or Condition Treatment
Fever Slice a white potato and put it in a white sock
under the bottom of the foot, then wrap a rag
around the head. When the potato gets as if it
were cooked, the fever will be gone.
Fever Put turpentine in a pan and place under the sick
person's bed.
Fever Place a raw red onion on the body to draw out the
fever.
Fever Warm gingerale, herb tea
Fever Alcohol bath, then rub body with a green lime or
coconut oil.
Cold Honey and lemon
Cold Cod liver oil to prevent a cold
Asthma "Vicks" salve
Castor oil with olive oil and sugar
Nyquil
Formula 44
Diarrhea Flour and water mixed together
Herb teas
Diarrhea Add corn whiskey to one teaspoon of white whiskey,
strike a match on it and let it burn. Then take a
piece of alum about half the size of a pea, put it
on a spoon and put the spoon on something hot.
Then mix it with the whiskey. Add a little milk
to it and give it to the person (adult or child)
with diarrhea.
Gastroenteritis Boiled water
Broth soups
Herb tea
Rash Herb tea
Rub honey and vaseline on rash
Chest pain Soda
High Blood pressure Vinegar and garlic
IV-7
(TABLE I: HOME REMEDIES, continued)
Illness or Condition Treatment
Overweight
Allergies
Infections
Cuts
Laxatives (patients were found to use laxatives to
lose weight prior to a health care visit).
Herbs
Herbal teas
Golden seal tea
Turpentine
IV- 8
including healer, herb doctor, root doctor, root worker, reader, advisor,
spiritualist, conjure man or woman, houngan or papaloi (voodoo tradition)
(Snow, 1978). Because each intermediary is considered to have unique
strengths and skills, both the persons wanting to place spells and the
persons wanting to remove them seek out the most powerful intermediary they
can locate — the former in order to place a spell that cannot be broken and
the latter with the hope of being able to break the spell.
Sometimes this healing power can work against patients which may lead
them to seek out mainstream care before resorting to the more dangerous
folk medicine cures. Interestingly, if a sufferer is cured after seeing a
traditional healer, no one is surprised and the traditional treatment is
credited with the cure (Webb, 1971). However, if the sufferer does not
improve, it is believed that it was because the individual was beyond hope,
not because the cure did not work. The folk healing system is based on
belief; successes have significantly more force than in mainstream
medicine and failures are less serious a blow because there is always the
possibility that the patient can be cured. Lack of knowledge or resources
are not issues in traditional healing. Several of the patients in the
focus groups expressed an awareness of witchcraft but stated that they
neither believed nor participated in this type of activity.
C. ATTITUDE TOWARD AND USE OF MALN STREAM HEALTH CARE
PROVIDERS IN THE US.
Most low income Blacks, particularly those in urban areas. see a
physician at least once each year (Jackson. 1981) and there is little
evidence that they have significantly different expectations about these
encounters than the majority populations. They believe physicians should
be treated with respect and also want courteous treatment in return. They
expect the physicians to know what is wrong with them, to explain the
illness in clear terms and to suggest an appropriate treament. One study
(Scott, 1974) found that although Blacks are large users of the orthodox
health care system, their contacts tend to be superficial. Symptoms and
conditions which brought them in for care continued week after week, month
after month and were rarely cured. This study also that a Black family
will often use both private physicians and public clinics, sometimes at the
sflme time. This was found among the Black patient focus group participants
also. Participants stated that they use private physicians when they want
to be served in a timely manner, when they want better treatment, when they
need a form completed (such as a child's physical for school) or when they
wanted continuity of care, i.e., to see the same doctor who will have their
whole history in his files. Some patients may withhold information from a
physician to test his or her intelligence and skill and similarly, some may
believe physicians should be able to diagnose without any patient input
(Jackson, 1981).
Some Blacks may be distrustful of non-Black physicians after learning
about or experiencing condescending, disrespectful, or otherwise
prejudicial treatment. Most low income Blacks' primary concern is that the
physician is competent. The race and sex of the practitioner are secondary
to this, but may still be very important, i.e., many of the patients in the
IV- 9
focus groups expressed a preference for female physicians because they were
more careful to explain information about the illness and treatment to
them.
The Black patients in the Region II groups displayed few conflicts
with the expertise of health care providers. Many did, however, express
the belief that faith in God and in the provider are important to the
healing process.
A feeling of nervousness or slight fear when seeing a physician was
expressed by many Region II patients . This nervousness resulted in
soliciting information from and giving more information to support staff
than to physicians. Patients utilized staff to translate physicians'
medical terms into "plain English" and to give information or pose
questions that they expected would be passed on to the doctor. Patients
felt more comfortable telling staff members about personal problems and
home remedies. This trust in staff and reluctance to confide in doctors is
due to many factors, including some of the following. At the centers where
these patients were served, the staff were of the same culture as the
patients whereas the physicians usually were not. The patients felt more
comfortable with staff. Secondly, a number of Black patients feel many
non-Black doctors are prejudiced against them. They are also afraid that
doctors will get upset over the use of home remedies and feel the staff can
"translate" this information so that the physician will not get angry.
Fourthly, some Blacks hold to the traditional belief that a physician
should be able to diagnose an illness without any information from them.
Finally, some Blacks fear that physicians will "steal" their home remedy
and transform it into an expensive prescription drug.
Although most low income Blacks in urban areas see a physician at
least once per year, some percentage of this group also use the services of
a non-mainstream practitioner. At least one researcher has found that a
number of Blacks use a variety of mainstream and non-mainstream
practitioners simultaneously (Scott, 1974). The mainstream providers may
be sought after other healing attempts have been tried and failed or they
may be used to confirm the success of a folk cure. In other instances, the
doctor may be seen to alleviate symptoms but the folk practitioner is seen
to effect the "cure." Sometimes physicians may be seen as capable of curing
only environmentally caused diseases, other times not (Snow, 1974).
Persons who believe themselves to be victims of a spell may see a
physician prior to, concurrent with, or after seeking help from a
folk/magical healer. When dealing with patients who believe their symptoms
to be the result of hexing, it is probably wise for a physician to
determine the extent of the individuals belief in witchcraft. Otherwise,
the physician may inadvertently confirm the patients fears about the
seriousness of the ailment. Patients may interpret uncertainty about the
cause of an illness or a request to wait a few days for test results as
confirmation of a hex. In the patient's mind, this would reduce his/her
likelihood of cure and he or she may not return. Although no members of
the Region II patient group said that they used traditional healers, they
knew of them and did admit to the use of traditional and home remedies.
Once the Region II patients found a physician they liked, they were
very loyal to him or her and would travel long distances to maintain the
relationship.
IV- 10
1 . Characteristics and Training Blacks Consider Desirable in a Physician
In general, most of the characteristics that Blacks feel physicians
should have are ones relating to their personal qualities such as how they
treat patients and their ability to communicate. Black patients felt that
physicians should work to develop a good rapport with their patients,
should be open in their communication and should take time to answer the
patients' questions. Patients expressed the desire that physicians
communicate with them in terms they can understand but at the same time
treat them as if they have intelligence and not be condescending. They
felt that physicians should be caring and interested in them, respectful
and concerned. Patients felt it was important to see the same doctor at
each visit so that a rapport and accumulation of knowledge about their
medical history could occur. Some practical advice was also offered by the
patients. They felt that whenever a change in physicians was to occur, the
"old doctors" should introduce the new doctors to the patient in person
rather than on paper. Also, they suggested that a physician should not
pretend that he or she knows everything and should call in a colleague if
he or she is unsure about something.
2. Advice from Staff for Incoming NHSC Physicians
To orient themselves to the clinic and community, staff of the Region
II centers stated that physicians should learn about the culture of the
community to gain a general idea of the context from which the patients
come. Physicians should realize however that "not every person will fit
that picture exactly." Staff felt it was important for physicians to come
with a open mind, to learn as much about the system as possible and to
accept the patients as they are. Staff also advised physicians to treat
the patients as human beings, to say hello and introduce themselves to
them. Aside from the courtesy of this, staff said it served a practical
value as well because many patients did not know the name of the physician
they saw at the last visit.
To help in their orientation, staff felt that physicians should be
given a thorough tour and explanation of the clinic and how the internal
systems function, where supplies, instruments and equipment are kept and an
introduction to staff with explanations as to their roles. To develop
relationships, staff felt that physicians should make an effort to get to
know them.
Regarding the patients, staff had this advice for physicians:
patients may be embarrassed and hesitant to tell the physician about some
things such as bleeding, a discharge or giving a urine specimen. Staff
stated that, because patients have seen them over a period of time, they
trust the staff and view them as friends. The patients feel more confident
in talking with the staff and relate to them more openly than with the
physician. This perception was confirmed by the patient focus groups.
Staff also warned that some patients are con artists and may present
confusing information. In these cases, staff felt that the physician
should trust the judgement of the staff.
IV-11
The staff also warned that their Black patients consume a lot of salt.
The diet of Blacks, of course, varies within the population. Some Blacks,
have a diet that consists primarily of "soul food" which includes a lot of
pork. Those who are of southern origin may be relatively low consumers of
fresh vegetables and citrus fruits but heavy consumers of flour, fat,
rice, grits, cornmeal, sweet potatoes, and in small amounts, fish, poultry
and meat (especially salt pork, bacon and fresh pork — Lowe, 1973).
D. IMPLICATIONS FOR PROVIDERS TREATING LOW INCOME BLACK PATIENTS OR
WORKING WITH LOW INCOME BLACK STAFF
As previously stated, it would be inappropriate for a NHSC provider
working with a low income Black population to assume that all, most, or
even the majority of his or her low income Black patients' health beliefs
and practices are described in the preceeding pages. With this point in
mind and recognizing that each provider has an individual style of
practice, the following list includes examples of situations or issues that
might arise when providing health care services to low income Black
patients or working with low income Black staff members.
1. In treating a low income Black patient it would be wise for a
physician to determine if the patient (or the parent if the
patient is a child) is using a traditional or home remedy
including any alterations in diet.
2. If a patient seems to believe that an illness is due to
unnatural causes, it would be wise for the physician to
determine to what extent the patient believes in witchcraft.
Any questioning about beliefs in witchcraft must be done
carefully so as not to alienate the patient who does not
ascribe to these beliefs.
3. Some patients may not seek care for a very serious illness if
they believe it to be caused by witchcraft. They may,
however, consult a physician for another illness which they
believe to be of natural causes — never telling the physician
about the "unnaturally" caused ailment. Therefore,
physicians might want to ask patients if they are
experiencing any other pain or physical problems other then
the one they came in for.
4. Many cultural groups lack a concept of chronicity of illness
or believe the idea that a physician's first therapeutic
modality should be immediately successful or else nothing can
be done. They may also view failure of a first treatment as
a loss of face for the physician, should it be brought to his
attention and therefore may not return if a condition
continues or worsens. To avoid the situation in which a
patient will not return if a condition worsens, a physician
might want to explain the process and course of the disease
in appropriate terms to the patient and encourage them to
return if the condition worsens.
IV-12
5. Because patients are generally more willing to confide in
staff, physicians might utilize staff to find out more
information relevant to a patient's case.
6. In giving explanations of an illness or treatment, it is
important to use terms patients understand. This is
especially important in achieving compliance from patients.
Physicians can test patients' understanding by having them
repeat instructions back to them.
7. All patients are sensitive to a physician's manner and
communication skills. Black patients may be particularly
sensitive to disrespectful or brusque treatment by non-Black
physicians and may interpret it as racism. Physicians should
treat patients and their health beliefs respectfully.
8. Non-Black physicians should learn some basics about the
culture of low income Blacks so that behaviors of either
staff or patients are not judged out of context.
9. It is wise that physicians learn about the staff and their
job functions and to use staff appropriately.
10. Health centers should provide some training opportunity for
their physicians to learn about the culture of the patients
and the community.
11. When possible, physicians might take and make opportunities
to provide preventive education to Black audiences as most
are desirous of this information and are not as likely to get
it through typical mass media and social relationship
channels.
12. When appropriate, physicians might question the use of salt
and fat in the diet, as low income Blacks may be heavy
consumers of both.
IV-13
BIBLIOGRAPHY:
LOW INCOME BLACK HEALTH CONCEPTS AND PRACTICES
Bryant, Carol Anne (1982). The Impact of Kin, Friend and Neighbor Networks
on Infant Feeding Practices. Social Science and Medicine 16.
Cappannari, Stephen C. et al (1975). Voodoo in the General Hospital, a Case
of Hexing and Regional Enteritis. Journal of the American Medical
Association 232.
Coulehan, John L. (197 9). Hypertension Followup in an Urban Population.
Public Health Reports 94.
Fabrega, Horacio and R. E. Roberts (1972). Social-Psychological Correlates
of Physician Use by Economically Disadvantaged Negro Urban Residents.
Medical Care 10.
Gylys, Julius A. and Barbara A. Gylys (1974). Cultural Influences and
the Medical Behavior of Low Income Groups. Journal of the National
Medical Association 66, No. 4 (July).
Hall Arthur L. and Peter G. Borne (1973). Cultural Influences and the
Medical Behavior of Low Income Groups. Journal of the National
Medical Association 66, No. 4 (July).
Harris, Rachel (1979). Cultural Differences in Body Perception During
Pregnancy. British Journal of Medical Phvchology 52.
Jackson, Jacquelyne Johnson (1981). Urban Black Americans, in Ethnicity
and Medical Care ed. Alan Harwoood, Cambridge, Massachusetts:
Harvard University Press.
Krug, Earnest F. (1974). Folk Medical Beliefs. Annals of Internal Medicine
81.
Linn, Margaret W. et. al. (1980). Self Addressed Health Impairment and
Disability in Anglo, Black and Cuban Elderly. Medical Care 89, No.
3.
Satcher, David (1973). Does Race Interfere with the Doctor-Patient
Relationship? Journal of the AMA 223.
Scott, Clarissa S. (1974). Health and Healing Practices Among Five Ethnic
Groups in Miami, Florida. Public Health Reports 89, No. 6
(Nov. /Dec).
Scott Clarissa S. (1974). The Relationship Between Beliefs About the
Menstrual Cycle and Choice of Fertility Regulating Methods Within Five
Ethnic Groups. International Journal of Gynecology and Obstetrics.
13.
Snell, John E. (1967). Hypnosis in the Treatment of the "Hexed" Patient.
American Journal of Psychiatry 24, No. 3 (September).
IV- 14
(Bibliography/ Black cont.)
Snow, Loudell F. (1974). Folk Medical Beliefs and their Implications for
Care of Patients: A Review Based on Studies Among Black Americans.
Annals of Internal Medicine 81 .
Snow, Loudell F. (1978). Sorcerers, Saints and Charlatans: Black Folk
Healers in Urban America. Culture. Medicine and Psychiatry 2.
Vail, Anthony (1978) Factors Influencing Lower-Class Black Patients
Remaining in Treatment. Journal of Consulting and Clinical Psychology
46, No. 2.
Verbrugge, Lois, M. (1979). Medical Care of Acute Conditions, United
State. 1973-1974. DHEW Publication 79-1557. National Center for
Health Statistics.
Web, Julie Yvonne (1971). Louisiana Voodoo and Superstitions Related to
Health. HSMHA Health Reports 86, No. 4.
Weidman, Hazel H. (1978). Miami Health Ecology Project Report: A Statement
on Ethnicity and Health. Department of Psychiatry, University of
Miami School of Medicine. (Mimeo).
Wheeler, Madeline and Sanobar Q. Haider (197 9). Buying and Food Preparation
Patterns of Ghetto Blacks and Hispanics in Brooklyn. Journal of the
American Dietetic Association. 75, (November).
Wintrob, Ronald M. (1973). The Influence of Others: Witchcraft and Root
Work as Explanations of Behavior Disturbances. The Journal of Nervous
and Mental Disease 156, No. 5.
DIAGRAMS OF FEMALE AND MALE BODIES:
ENGLISH/HAITIAN
■ENGLISH/ SPANISH
ENGLISH/SPANISH DIAGRAM
tead/la cafcsza
cuter ear/la craja
nose/la nariz
nack/el cusSo
breasts/lcs senos
cfcast/eJ pacfco
stomach/al estoraoc
^™»^
knsa/IarccDa
eya/d ojo
mcuth/Ia bcca
tfrcat/la csrssrta
sfcoidsr/el hcnfcro
arm/eJ brazo
fingsr/el dado
h/p/la cadar
vagina/la vagina
leg/la piema
— antta/d tcfcOo
fcot/d pta
<«.s
ENGLISH/HAITIAN CREOLE DIAGRAM
ttroat/gaoan
shoddsr/zepbl
chest/pwatrti
stomach/lestomack
hand/man
eye/zie
nose/nen
— mcuth/bcuch
nsck/cou
fincar/dwet
leg/jarm
foot/pie
( back/do)
ENGLISH/SPANISH DIAGRAM
head/la cafcaza
outer ear/la creja
nose/la nariz
reck/e* cuslJo
chast/al pscho
stomadVei estomago
tand/la mano
tHcfi/ai musSo
knaa/la rocf3a
eye/ei ojo
mouth/la boca
threat/la ssrgsnta
shaJdsr/eJ hcnrfcro
arm/el brazo
hip/la cadera
finger/el dado
leg/la piema
arkla/eltcfcDo
foot/al pia
ENGUSH/HAiTlAN CREOLE DIAGRAM
head/At
ear/Ay zorey — J£ ~y ,-$
ttroat/gagan'
shotidar/zepbl
chest/pwatrin
stomach/testomack
hand/men
tttgi/kwis
knee/jenou
ankle/chevi
eye/zis
nose/nen
mcuth/bcuch
rack/ecu
foot/pie
JK'
Live Music Archive
Librivox Free Audio
Metropolitan Museum
Cleveland Museum of Art
Internet Arcade
Console Living Room
Books to Borrow
Open Library
TV News
Understanding 9/11