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 ima ge 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") MgC0 3 ("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 b e 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 b e 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 o f 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 in volves treating the patient as an individual and building rapport before begi nning 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 t o 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 a s "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'