Healers, Deities, Saints and Doctors: Elements for the analysis of medical systems

Sot. Sci. Med. Vol. 29, No. 4, pp. 487496, 1989 0277-9536/89 S3.00 + 0.00 Printed in Great Bntain. All rights reserved Copyright 0 1989 Maxwell Pcrgamon Macmillan plc

HEALERS, DEITIES, SAINTS AND DOCTORS: ELEMENTS FOR THE ANALYSIS OF MEDICAL SYSTEMS* _

DUNCAN PEDERSEN and VERONICA BARUFFATI

Casilla 2117, Lima 100, Peru

Abstract-This article provides the basic elements for the discussion and analysis of medical systems and their inter-dependency, with special reference to Latin America and, in particular, to the Andean countries.

In a culturally diverse and socially stratified population, such as in contemporary Latin America, medical systems constitute a social representation resulting from the historical relationship between autochtonous medical cultures and those from other latitudes. The impregnation of scientific and popular knowledge results not only in the incorporation (and often expropriation) of folk in professional or scientific medicine, but also in the increasing ‘medicalisation’ of popular and traditional therapeutic practices. The emergent ‘popular’ medical system draws from both the professional and folk models, and in its actual practice, integrates both popular beliefs and materia medica with elements drawn from popular religions and pre-Hispanic deities. The degree of competitiveness, co-operation or ‘integration’ among medical systems depends mainly on the asymmetrical distribution of power and resources, and is conditioned by the population’s behaviour in the management of disease. Existing pluralist systems of health care reveal a valuable array of survival strategies, which far outreach the proposals for integration called for by official sectors. On the other hand, knowledge derived from traditional medicine can contribute to the development of new models of clinical practice and to the expansion of the conventional epidemiological model.

Key wjords-medical systems, traditional medicine, healing cults, Andean countries, Latin America

1. INTRODUCIION

Although diseases did not begin with man, they constitute an inextricable part of life itself. In every human society, at any point in history, diseases have generated some form of response aimed at interpreting, controlling, preventing, alleviating repairing, curing or healing injury, illness and disease.

Reactions to disease-or rather to the noxa, stress or trauma--can be seen from this perspective as either adaptive and individual responses of a biological nature, largely determined by the genetic code; or they can be a deliberate response of a social nature, with varying degrees of complexity, generated by the group, clan or family, or by society as a whole. All these forms of deliberate response to disease, regardless of their nature, are in essence, medical, and constitute what will be referred to as medicine in this analysis.

Some authors refer to the structural and organis- ational aspects of medicine and health, using the terms medical systems and health systems. Although for some, health systems and medical systems are equivalent, it is necessary for the purposes of this article to establish the different meanings of each term. Health systems comprise the whole array of elements or components of the broader social system which are related to the health and physical, mental and social well-being of the population. We shall reserve the term medical systems for the organised array of human resources, technologies and services specifically designed for the development and practice of a medicine for individual or collective health care.

In a more strict sense, medical systems are made up

- *This article is based on a paper presented by the authors

at the IIlh Internarional Congress of Traditional Medicines, held in Lima, Peru. 26-29 June, 1988.

of a more or less uniform set of schools, hospitals, clinics, professional associations and agencies who train personnel, maintain an infrastructure for biomedical research and deploy a network of services of varying degrees of complexity for the prevention, curing, care and rehabilitation of the sick. For the analysis of medical systems in this document, we would rather adopt a broader and more inclusive meaning, as proposed by Leslie [I], and treat the medical systems as pluralist structures wherein medical practices maintain a competitive or com- plementary relationship in the management of disease.

Every medical system has its own distinct and more or less organised set of technologies (materia medica, drugs, herbs or procedures such as adivination, surgery or acupuncture) and practitioners (doctors, nurses, dentists, pharmacists, therapists, shamans, healers, bone-setters, herbalists, midwives, etc.) with their own ideological substratum (concepts, notions and ideas) which form an indissoluble part of the cultural repertoire of society.

As will be seen below in the second section of this paper, each one of these dimensions: ideological substratum, practitioners and technologies, are found in varying proportions resulting in different relationships among medical systems. These can range from antagonism or competitive rivalry, through comple- mentarity or co-existence, to various structured forms of selective integration of their components. We shall see in this analysis, that in a socially stratified and culturally diverse society as found in Latin America, the relationships between medical systems reveal an asymmetrical distribution of power in society; between a dominant medical system (with a marked tendency towards institutionalisation and bureacrati- sation) and one or more subordinated medical systems.

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488 DUNCAN PEDERSEN and VERONICA BARUFFATI

It is worth pointing out that medical systems are, in fact, an artefact or conventionalform of simplifying the very complex relationships of the dynamics of social and individual behaviour confronted with disease in the health-seeking process. The systemic approach-widely used amongst health planners and social scientists-represents the materialisation of an artefact created by our own social organisation in our Western way of thinking, and therefore does not necessarily have equivalents or is applicable as such to other societies or cultures [2, p. 63; 31.

Although the advantages are obvious of a systems analysis for the descriptive study of medical structures and organisations, its limitations should also be pointed out in dealing with the transactions and interaction between doctors, healers and patients. The approach discussed below in the third section, proposes some hypotheses and instruments to facili- tate the qualitative analysis of these dynamic processes from a more structural perspective.

In the fourth and last sections we will raise some questions and discuss a few alternatives for ‘integration’ of traditional medicine with modem medicine in the Latin American region.

2. MEDICAL SYSTEMS

Attempts are being made in several parts of the world to make changes in health policies, legislation and the administration of services, in an effort to modify the relationships between the various existing medical systems in order to raise health levels and increase accessibility to health services. This has led to a vast and diverse range of experiences.

At the one extreme, there are the cases of countries who restricted the medical practices of the official sector to ‘scientific’ medicine, for example in Austria, Belgium, France, U.S.S.R., Cuba and other socialist countries. In the latter, the provision of medical care was assumed by the state, limiting the practice of medicine to duly accredited professionals, and the use of medical biotechnology in diagnosis and treatment was the only officially authorised method, thus leading to the virtual disappearance of traditional or folk medical practices as an alternative care system.

At the other extreme, there are those countries who recognise other medical practices on a par with modern medicine. In several Southeast Asian countries (India, Bangladesh, Pakistan, Sri Lanka, Burma), the traditional medical systems based on Ayurveda and Unani have achieved legal recognition and state support; and in other countries, as is the case of China, there has been effective integration of different systems to form one single medical system with the combination of alternative technologies for the diagnosis and treatment (acupuncture, acupressure, mas- sage, moxibustion, herbs and patent drugs), and the incorporation of traditional practitioners in the health care services.

Towards the centre of this spectrum are the majority of countries where the co-existence of different medica! systems come together in a pluralist and diversified health care system. In most Latin Ameri- can countries, including the countries of the Andean region (Colombia, Ecuador, Peru and Bolivia),

medical systems are pluralist structures where different medical practices and traditions co-exist. In these countries, autochtonous medical traditions have blended with other medicines, brought by the Euro- pean colonial expansion, in a complex process of hybridisation of medical knowledge (of Greek, Iberian and later African origins), submerged in the religious syncretism of pre-Hispanic deities and Christian saints. During independence, and as new republics appeared on the continent, these hybridisation processes became more obvious, and the introduction of new forms of economic dependence were correlated in both the cultural and technological domains. The paradigms derived from the natural sciences blended with local medical traditions and practices, thus giving birth to modem medicine. Since then, the medicine we now refer indiscriminately to as academic, modern or official, Western or formal, cosmopolitan or scientific has found a place for itself alongside these transactional processes of medical traditions, and at the same time has not only incorporated in the construction of its own body of knowledge some of the concepts from folk or traditional medicine related to aetiology and pathogeny, but has also expropiated from their therapeutic wealth the use of medicinal herbs and several active principles extracted from native taxonomies.

There are many examples in the history of the Latin American people where those in power have tried to eradicate the indigenous medical ideologies, practices and materia medica. Whereas in some countries the ruling class remained tolerant or in- different to the presence of traditional medicine practices, in others a more radical posture was adopted, in which traditional medicine and its ‘mentality’ was considered retrograde and undesirable, to be replaced entirely by modern ‘scientific’ knowledge and practices. Only a lack of funds has prevented the flooding of the traditional medical practices market with ‘better’ modern technologies [4, p. 9371. In many Latin American countries today, the sanitary codes which regulate the professional practice of medicine still reveal these underlying attitudes.

More recently there have been attempts to re- evaluate traditional medicine practices and to encour- age the collaboration between traditional and modern medicine. These attempts have been promoted in some cases by ‘nationalist’ movements, or fuelled by ‘indigenistas’ (pro-Indian movements) to rescue folk medicine, or simply as a strategy for extending health care coverage at low cost. These initiatives have received support and have been encouraged by the adoption of resolutions by governments at an international level, as in the WHO.

Nevertheless, in Latin America, ambiguity still prevails when it comes to the adoption of policies or national strategies which favour the integration of a decentralised and pluralist medical system involving the participation of healers, midwives and other folk specialists, in the official system of medical care delivery. As a result, activities in this area are usually limited to descriptive studies or the training of personnel, while the experiences of collaboration or ‘integration’ of medical systems have been left to

Healers, deities, saints and doctors 489

local, usually non-governmental initiative, or have been developed as ‘showpiece projects’ of national and foreign teaching and research centres.

Most of these experiences are simply aimed at recuperating knowledge related to traditional medicine, whereas others have tried to incorporate the use of modern technologies in the traditional sector, or attempts have been made to partially integrate materia medica (e.g. the use of herbs and medicinal plants) or to ‘intercalate’ traditional medical skills in health programmes of the official sector (e.g. traditional midwives).*

In brief, in the case of Latin America, despite the vast amount of research that has been carried out revealing the existence of different belief systems and traditional medicine practices, and despite numerous attempts at the partial integration or ‘intercalation’ of traditional with official medicine, most of these experiences have remained local, with little national repercussion and results which are rarely diffused and evaluated. National health systems have still not managed to incorporate or integrate the practices, technologies and the practitioners of traditional medicine into the official systems of health services in a structured, equitable and lasting fashion. Nor have they managed to synthesise ideologies and beliefs or to formally ‘integrate’ the paradigms of traditional and official medicine under one medical system.

3. NEW PERSPECTIVES FOR THE ANALYSIS OF MEDICAL SYSTEMS

Morbidity surveys and experience accumulated by various researchers [12-20]t in different countries of Asia, Africa and Latin America, have revealed the multiplicity of therapeutic uses and recurrence to different sources for treatment by the population. Most of these authors observe that 70-80% of reported illness episodes are managed outside the official medical system, either in the traditional medi-

*There have been several such attempts in Peru beginning in the 30s with a pioneer project for the altiplano in Puno where sanitary brigades incorporated healers and other voluntary personnel in what were called ‘rijcharis’ [S]. In recent years in the Amazon and southern Andean regions [6-81, there has been a mushrooming of this kind of primary health care programme where some traditional medical practices are promoted (usually limited to the use of medicinal piants) in courses for training health promotors and traditional birth attendants. In very few instances traditional healers are incorporated in the selective care of some health problems in rural popu- lations. These programmes are often carried out under the auspices of non-government organisations. There is a much wider variety of ethnographic studies related to beliefs, procedures. herbs, and traditional medicine pre- scriptions, from the classic works on popular medicine [9] to more recent works directed at scholars and the general public [lo. 111.

tAxel Kroeger [21] did a comprehensive revision of morbidity surveys carried out on urban and rural samples in 19 countries in Asia, Africa and Latin America, reported between 1966 and 1981.

$The departments of Ayacucho, Apurimac and Huanca- velica (which together represent 6.6% of the total population) were excluded from the National Survey as they have been declared in a state of emergency.

cal system, by self-medication or by simply doing nothing to modify the evolution of the reported episode. Moreover, of all the patients who initiate medical treatment, about half of them interrupt or abandon treatment as prescribed by the professional WI.

These results reported by various community studies or small-scale surveys have been confirmed by national health surveys. In fact, in recent years, Costa Rica, Colombia, Brazil, and more recently Peru have carried out national surveys which include quantitative data about perceived morbidity and the utilisation of health services.

In 1984, the National Nutrition and Health Survey was carried out in Peru [23], on a random, stratified and multi-stage sample of 19,277 households of 95,321 people throughout the country.1 The official survey results indicate that of the total surveyed population, 32,000 (35%) reported symptoms (illness and/or accident) in the 15 days prior to the survey. Of these, only 5500 (17%) consulted a health professional (doctor, dentist, nurse or obstetrician). Of the others, 14,700 (46%) made no consultations nor took any therapeutic action; 9900 (31%) resorted to self-medication; and the remaining 6% consulted a pharmacist, a ‘sanitario’ (male nurse) or a healer (this last figure is most probably under-reported).

In other words, of the total .morbidity reported by the Peruvian population at one given moment, more than 80% opted not to seek professional care. According to the results of this national survey, illness episodes are largely managed at home or by self-medication.

This information confronts us with the riced to reformulate the hypothesis of the existence of medical systems as alternative and mutually exclusive agents, in order to obtain a more dynamic view of the reality where these systems are in permanent interchange and reciprocal interaction, a process which has been underway ever since first contact was made with different medical traditions. On the other hand, and as we will try to demonstrate below, people do not necessarily perceive these systems as discrete and autonomous systems which interact either com- petitively or complementarily, keeping distance and independence from each other.

The representatives of official medicine, for their part, defend the biomedical model regardless of social differences, and although they recognise the existence of other medical practices, they frequently treat them as charlatanism or superstitions, or as a disappearing historical vestige.

Practitioners of traditional medicine, on the other hand, have a distinctive view of their own medical system and they act according to the different interpretative models accessible to them (natural, herbal, spiritual, magic or specialised), but they also show a tendency to overestimate and consider themselves infallible, although they do concede that modern or official medicine is superior in the treatment of certain symptoms and diseases.

The differences pointed out here in the perception and interpretation of illness, disease and health care systems are determined by the relative social position of individuals in society as a whole and are strongly shaped by their own individual experience and cultural

490 DCJNCAN F%DERSEN and VERONICA BARUFFATI

Fig. 1. Explanatory models: traditional or folk, professional and popular. The proximity, superposition and size of the explanatory models represented are relative and figurative.

system. We shall now look at the relationship between the medical systems from this so&o-structural and cultural viewpoint, where medical systems are not perceived as isolated and mutually exclusive, but rather, as part of a dynamic relationship of permanent interchange and reciprocal interaction.

3.1. Medical systems as cultural systems: the explana - tory models

In 1973, Kleinman put forward the notion that medical systems should be defined as cultural systems and that for this reason it would be impossible to understand medical systems without understanding the cultural context of which they are part. From this perspective, medical systems are submerged in a symbolic reality, giving form “ . . . to different symbolic realities within which illness and healing occur” [24, pp. 159-1601.

The main ‘clinical’ functions of medical systems are: the construction of the illness experience, the cognitive management (denomination, explanation, classification, etc.) and the therapeutic management or ‘healing practices’ [24, p. 160].* According to Kleinman, there exist among specialists (doctors, healers, etc.) and the population, a whole host of original medical beliefs about disease and illness which can be divided into three different ‘explanatory models’: professional, folk, and popular, depending on whether the professional, the healer, the patient or their relatives are interpreting the disease or illness. The explanatory model contains beliefs for one or all of the following: aetiology, the onset of symptoms, pathophysiology, the course or evolution of sickness and treatment [25].

It is important to establish that in Kleinman’s (and other authors who share his viewpoint) opinion, explanatory models are individual manifestations and therefore vary from person to person within the community. They also change with time, depending

*Kleinman also incorporated the ‘management of death’ as a fourth medical care function of medical systems [24, p. 1601.

on the medical experiences and the succession of clinical encounters with the explanatory models of professional doctors or practitioners of traditional medicine [26, p. 2671.

3.2. The popular explanatory model

In the case of Latin America, the folk and professional explanatory models share a lot of common ground, despite their different traditions and historical backgrounds. The popular sector in turn brings together a range of health and disease beliefs: its materia medica comes from both the folk and professional models, and elements of popular religion and pre-Hispanic deities all add to make up the popular explanatory model (see Fig. 1).

This popular model is also socially stratified &- cording to class, and ethnic and cultural variations, and in many cases to the migration of the individual and his family, who are subjected to the acculturation process imposed by the urban-industrial context of their destination.

In the case of Peru, which is in some way typical of what happened in Latin America, the country has been going through a severe social and economic crisis, aggravated in recent years by the foreign debt (U.S.S16,500 millions). This added to massive migration from the rural to urban areas, has resulted in high unemployment levels with alternating periods of inflation and recession. The state has widened and increased its role in the management of the economy through the expansion of the taxation system and the nationalisation of the banks, leading to an increase in the bureaucratic control over banking, commercial activity and productive sectors.

More and more segments of the population, especially in urban areas, are experimenting with different survival strategies around which two main economic systems are organised: the formal, official and bureacratic sector, which despite its legal status, is weighed down by excessive regulations; and the ever-increasing popular response, known as the ‘in- formal’ sector of the economy which operates beyond the realm of official dispositions and regulations, usually as an individual or family, small-scale


operation filling the gaps left to them by the official sector.

This led to a growing incapacity of state insti- tutions and the so-called official sector to exercise control over the productive and service mechanisms, and for this reason in the mid-80s this culminated in the uncontainable and massive overflow of the popular, with provincial multitudes inundating the urban areas and causing profound alterations in national lifestyles leading to what has become known as the ‘popular overtlow’ [27]. In the cities, the explosion of needs and aspirations was far greater than what the antiquated and insufficient state apparatus could fulfill. The institutional formality of schools, hospitals and the urban infrastructure of services was completely overcome by a turbulent and unusual array of various revindicative and argumen- tative claims, and a growing unsatisfied demand for services.

The economic and social crisis has not only affected urban areas but also large sectors of the rural population. In certain rural areas of the Andean countries, the economic depression, the lack of credit and selective migration of the active population has been aggravated by the clandestine cultivation of the ‘sacred plant’: coca. In Peru, estimates reveal that 150-200,000 ha are dedicated to coca cultivation, reaping a net utility per hectare for the agriculturalist of 4-6 times that of other traditional crops (coffee, cacao, etc.). The infrastructure set up by the drug traffickers for the processing of coca, and the violence deployed in its purchasing and pricing have led to radical changes in the lifestyles of the campesinos in certain parts of the country. This violent acculturation and maladaptation process has resulted in an explosive increase in the consumption of manu- factured goods, including brand drugs and pharmaceutical products.

We can see that as a result of the current crisis situation and of the ‘popular overflow’, with its uncontrollable surge of unsatisfied demand, there is an impregnation and intertwining of scientific and popular knowledge which generates and expands the popular explanatory model of health and disease, which in turn is determined and modtjied to a large extent by this context. In the Andean countries, the popular explanatory model is in constant process of production. accumulation, interchange and trans- formation of medical knowledge which represents not only an important part of the cultural patrimony but also a vital strategy for survival.

The impregnation and intertwining of scientific and popular knowledge occurs in several directions and generates continuous changes inside the explanatory models. Below we shall refer to two outcomes of these processes: the ‘popularisation’ of the professional model: and the ‘medicalisation’ of the popular or folk model.

3.2.1. The popularisation of the professional model. On the one hand, this phenomenon of impregnation of the folk and popular in the professional explanatory model, explains why we find in today’s professional model not only traces but also other folk elements, recently incorporated especially on the therapeutic and ethiopathogenic level, resulting in a ‘popularisation’ of the professional model.

Although the biomedical paradigm is at the centre of the professional explanatory model, the incorporation of folk or popular elements is a result of wider social processes, parallel to the transactions and negotiations which take place in the clinical encounter with patients, and in the interchange with other professionals. In this way, in daily medical practice, the germ theory co-exists without contradiction with the beliefs about the harmful effect of certain food- stuffs (e.g. milk, unripe fruit or vegetables as causes of diarrhoea), or the prescription of a modern drug is accompanied by a recipe for a popular medicine. Modem or official medicine has not only_ incorporated or integrated concepts and therapies from other medical systems, but rather has expropiated many of its elements (e.g. plants of the native tax- onomy for its own materia medica). Professional medicine has even expropiated the language of the people and its productive capacity in health, relegating people to the passive role of consumers of medical services.

3.2.2. The medicalisation of the popular or folk model. On the other hand, given that this process is bi-directional, many of the concepts, medicines and material or symbolic elements associated with scientific, occidental or modem medicine have penetrated and are present in the folk and popular explanatory models.

The popular sector is continuously integrating therapeutic resources from professional and folk medicine. For example, the ‘hot’ and ‘cold’ attributes, present in humoral medicine throughout practically the whole of Latin America are used not only in relationship to body states, illness, food and medicinal herbs, but also in relationship to brand medicines, as demonstrated in the case studies carried out by Tedlock in Guatemala. The popular sector ‘borrows’ information from the professional and folk sectors, and in its treatment mixes pharmacy medicines with herbs bought in the marketplace, grown in the backyard or brought from the hillsides. Whereas medicinal herbs are often used alone, without brand medicines, it is rare that medicines are used without herbs, to such an extent that modem drugs, far from replacing medicinal plants have been incorporated or added to the treatment [28, p. 10751.

The middle classes of the modem urban sector of Latin America are more informed nowadays about the ‘scientific’ aspects of medicine, and for this reason they demand more biomedical expla- nations in the construction of their own explanatory model, and they tend more towards self-medication. Although the popular classes do tend to recur more to folk medicine, they are targets of publicity campaigns to increase the intake of over-the-counter drugs. Various studies report an explosive increase in self-medication and the consumption of pharmaceutical products such as antibiotics or other prescribed medicines, often in combination with herbs and other popular products with medicinal attributes.

In a relatively recent survey (291 carried out on three social strata (high, middle and low) of patients in metropolitan Lima’s medical services, it was shown that:

492 DCWCAN PEDERSEN and VERONICA BARUFFATI

(a) Between 62 and 85% of cases attended had already used some other therapeutic resource before consulting a doctor. Although the figures were high in all three social groups, they were highest among the lowest class of salaried workers, ambulant vendors and the unemployed.

(b) Between 51 and 64% of cases attended had already taken some drug or brand medicine before going to the doctor. Self-medication was most fre- quent in middle and high classes. The pharmacist was responsible for the greater use of medicines amongst the popular sector.

(c) The least used resource was the traditional or folk (either alone or combined) treatment: 3% amongst professionals, owners or company man- agers, 11% amongst businessmen, employees and labourers; and 35% amongst ambulant vendors, salaried workers and the unemployed.

This encounter of the professional and folk models does not only occur in the urban setting, but also in remote rural areas where the inhabitants have contact with other civilian and military authorities, mission- aries and itinerant health services. Although these villagers have a more folk cognitive notion of their illnesses, they overuse new therapeutic resources such as antibiotics or vitamins introduced by the official medical system, without incurring any contradictions in their cosmovision. These groups have adapted the indications and use of modern drugs to their own idiosyncrasy and explanatory model, attributing to them magic and supernatural effects, and prohibiting their use if certain foods have been eaten and if the transgression of taboos has affected the curative power [30, p. 871.

3.2.3. The medicalisation of healing cults. Another example of the medicalisation of the popular model is in the so-called ‘healing cults’ which have emerged in Latin America in relatively recent times and which have registered an important growth lately because, amongst other things, of the incapacity of the state apparatus to satisfy growing social demands. These cults are a magic-religious synthesis of elements of Afro-American religions, popular Catholicism, and beliefs derived from Allan Kardec’s spiritism introduced to this region towards the end of the nineteenth century. These healing cults usually operate in shrines or cult centres by invoking spirits who, through posssessing a healer-medium, advise on certain problems, perform surgery to magically extract tumours or diseased organs from the body, heal an illness or cure a disease. Voodoo in Haiti, the Umbanda cults in Brazil, the cult of Dr Adolph Fritz in the Brazilian north-west and other Brazilian cities*; the cult of Maria Lionza or the Siete Potencias Africanas (lit. translated as Seven African Powers) in Venezuela [33]; the cult of ‘la Difunta Correa’ (lit. translated as the deceased Correa) in Argentina; the cults of Dr Jose Gregorio Hernandez (also called ‘brother Gre- gorio’) which originated in Venezuela and spread to the Caribbean, Colombia and Ecuador; and the cult of

*In the case of Brazil, the cults of Ze Arig6, Edson Queiroz and other legendary healers reported in the literature [31, 321, focus on spiritism and the notions of incar- nation and possession.

Dr Moreno Catias reported in Costa Rica and other Central American countries [34], are all forms of healing cults of powerful symbolic content, increasing in popularity and use by people from various social backgrounds (although mainly from popular sectors) for the diagnosis and treatment of certain illnesses and diseases.

The medicalisation of the healing cults can be seen in the importance people attribute to the figure of the doctor and his medical procedures. According to Low, the biographies of Dr Hernandez and Dr Moreno Cafias portray them as mythical figures of surgeons specialised in Europe who returned to their countries to reform medical practices, appearing to their followers carrying a doctor’s black bag, accompanied by a nurse or assistant. These healing cults bring together symbolic elements of the image of the ‘doctor-hero’, the social reformer and the popular saint, and offer the low socio-economic groups the opportunity to have personal and more direct contact (also free of charge) with the divine and the medical. The skill, the clothing and other paraphenalia reflect- ing medical competence and technology which appear in the icons, represent the prestige and power popular classes attribute to modem medicine [34, pp. 146-1471.

In the case of Venezuela and the Andean countries, popular religion predominates in the healing cults, and it is likely that something similar occurs in the popular explanatory model on curing, where syn- cretic elements from Catholicism and deities of the Andean pantheon appear side by side with icons and symbols of modem medicine. In the case of Peru, there are various manifestations of curing associated with the Catholic religion, as can be seen in pilgrim- ages to sanctuaries and religious festivals which bring together thousands of faithful, e.g. the procession of the ‘Seiior de 10s Milagros’ (Lima); ‘Seiior de Luren’ (Ica); ‘Cruz de1 Chalpon (Motupe); and ‘Setior Cautivo de Ayabaca’ (Piura), as well as in the vener- ation of ‘domestic cults’ of images of saints, such as Saint Cyprian (the saint of healers and shamans), Saint Martin of Porres, and the cults to Melchorita, Beatita of Humay and Father Urraca [35, p. 19).

Lastly, note should be taken of how the popular explanatory model and some manifestations of popular religiosity, such as the curative and domestic cults, compete with other curative complexes of folk medicine.

The main Peruvian curative complexes, centred on the use of psychedelic plants, have been described by botanists and researchers since the beginning of the century [9,36] and more often and intensively studied over the last three decades. Chiappe and his collabor- ators have reported the extensive use of the San Pedro’ cactus (Trichocereus panachoi) on the northern coast, ‘Ayahuasca’ (Banisteriopsis caapi) and ‘Toe’ (Datura sp.) in the jungle regions of the Amazon, and ‘Wilca’ (Anadanthera colubrina, var. cebil) in the Andes [37]. According to these authors, the curative ceremonies which involve the preparation and intake of psychedelic substances* have maintained their traditional or folk orientation, while at the same time incorporating many religious elements from European and African traditions (imagery, prayers, types of fasting, the use of alcohol


and tobacco, fetishes and eau de cologne used in ceremonies, etc.), and other more recent ecstatic and curative experiences brought from Asia. Neverthe- less, none of these so-called ‘curative complexes’ are institutionalised. and for this reason there has been no record of cults, churches, or brotherhoods or formal association with religious denominations.

4. IS ‘INTEGRATION’ BETWEEN TRADITIONAL AND OFFICIAL MEDICINE AT ALL POSSIBLE?

Given this new perspective and context, is it possible to uphold the proposal of ‘integration’ of traditional and official medicine? And if so, how can it be achieved?

Apart from the ethno-botanical and pharmaco- logical studies on medicinal plants, flora in most Third World countries remains virtually unexplored [38, p. 1791. This is true for most Latin American countries, where we can confirm that the inclusion of ‘natural’ medicinal extracts or plants in the national pharmacopia is insignificant, and the increase in the number of medicines registered has meant that more valuable foreign currency is being designated to import drugs, medicine and patents.

As far as the practitioners of traditional or folk medicine are concerned, they have maintained their reputation and acceptability among the people. How- ever, because of the dwindling number of healers in relation to the population. their real accessibility has diminished. On the one hand, there has been a decrease in the absolute number of healers and other ‘specialists’-as stated by Foster in 1977 [39l-simply because those who die are not replaced; and on the other hand. the population growth and the sustained migration from the rural to urban areas modifies this relationship negatively and therefore limits the population’s access to the healers, particularly in urban areas. Most of the ‘great’ healers who have a regional influence over their clientele stay in the cities or more densely populated areas, whereas the local healers who work ‘part-time’ either because they are specialists or because they attend only on demand seem to have diminished, or at least they keep a ‘low profile’, although we have no reliable data to confirm this statement. From our field experience in the Andean region, the healers with whom we have worked have had many patients, several helpers and ‘officials’, but very rarely an apprentice. Although all healers admit to having had several masters and one ‘initiator’ (usually an older family member), very few admit to having had disciples, or to having ‘imtiated’ healers amongst their descendants or ‘compadres’.

In order to explain this situation, we would have to formulate another hypothesis whereby the structure of traditional medical systems in the Andean region

*We have been unable to find data which would permit the evaluation of current trends in the ceremonial use of San Pedro and Ayahuasca in relation to the diagnosis and curing of disease. It seems that Ayahuasca is used in combination with other hallucinogenic substances amongst colonos and mestizos in the Peruvian jungle, and that San Pedro is beginning to be used more frequently by migrants in the urban setting.

is today being transformed by the emergence of the popular model, and the appearance of an array of other elements which are part of the modernisation process and the mercantilisation of medical practices (such as the ambulant vendors, the pharmacists or re-sellers of medicines, ‘naturists’, etc.), by the rebirth and expansion of ‘healing cults’ and by the progres- sive and relentless medicalisation of traditional or folk medicine.

With regard to the use of traditional healers in primary health care strategies, Foster rightly pointed out that care should be taken not to oversimplify and assume that there are only two types of resources: traditional and modern. It is quite possible that nowadays, the ‘neo-traditional’ healers (spiritualists, naturalists, ‘injection-doctors’ and other therapists who use modem medicines) offer more medical care collectively than the traditional healers in the strict sense [40, p. 8491.

While this is the case with practitioners of traditional medicine, quite the opposite is happening in the official sector. According to figures presented by each country [41], the estimated number of doctors in Latin America is about 400,000, and the number of doctors per inhabitant varies from country to country (from 7 per 10,000 for Central America, to 20 per 10,000 in Chile and Argentina). Between 1960 and 1985, the number of schools teaching medicine in Latin American countries increased considerably, reaching a total of 250 officially recognised schools of medicine. Although there are no up-to-date facts about the production of doctors in this part of the world, estimates show that the supply of medical professionals is several times greater than the population growth. In fact, some countries have reported an annual increase in the number of doctors of between 10 and 14% (Colombia, Brazil and Cuba), which is three or more times the reported population growth rate for the same period (421.

Unofficial estimates show that by the end of the century another 300,000 doctors will be added to the present labour force. The social and spatial distribution of these professionals is unequal, as they prefer to congregate in the cities. At the same time, new corporative forms of medical practice are being introduced, leading to greater bureaucratisation of services, a marked tendency towards specialisation and a growing dependency on the use of sophisticated biomedical technology. In this process, the medical professional of liberal and independent tradition sees himself pushed into more rigid forms of salaried- employee status for practice [43, pp. 168-1711. Given this situation, it would seem contradictory to suggest the use of healers or other practitioners of traditional medicine in a market already saturated by professional resources where the practice of medicine becomes more and more complex.

On the other hand, the proposals for the ‘integration’ of medical systems have been launched from a very precarious platform, based on unproven premises, in often very contradictory language about the efficacy of the different medical systems, or simply without sufficient information at all. In most countries, proposals for integration come from the dominant sectors of official medicine without taking into account the opinions or attitudes of the very

494 DUNCAN F%DERSEN and VERONICA BARUFFATI

practitioners of traditional medicine. In Peru, sound- ings have been made to see whether there is interest amongst doctors and healers (bone-setters, prayer sayers, etc.) to work together. Whereas the former are mainly all negative in their stance, the latter see no advantage of such an association and even fear the loss of clients. Only the ‘charlatans’ would be pre- pared to run the risk of working together with a doctor in the hope of increasing their clientele and income.

No studies have been carried out to measure the effectiveness and the therapeutic efficacy of traditional medical practices. Nor has there been an assessment made of the possible iatrogenic effects or the real costs of such integration [44]. Likewise, little attention has been paid to the effect bureaucratisation and professionalisation would have on traditional medical practices, and it can be presumed that if national organisms and regional offices had to be developed for the evaluation, control, awarding or renewal of healers’ licences, the cost of such an operation would de-finance the bureaucracy of the respective sector, with the added risk of placing an explosive burden on the already precarious balance of labour in the health sector in our countries.

5. NEW QUESTIONS

If this is the case, we should not be asking questions such as how to integrate folk with official medicine, or how to integrate traditional healers into the official sector (with an increasingly complex bureaucratic and technological set-up) in order to use them more or better. Instead, we should be asking ourselves new questions and formulating hypotheses within this new context.

How to reach a more equitable distribution of health resources? How to create new work alternatives in health for a sector which will receive an oversupply of physicians to its workforce? How to expand or reform the conventional biomedical model? How to salvage the knowledge and practices of traditional medicine and how to incorporate them in the reformulation of health policies and in the designing of new health care delivery models?

As seen above, there exist, beyond the limits of modern and traditional medicine, other forms of healing or curing, to be found inside the popular explanatory model (especially in urban areas): natur- ism, bioenergetics, yoga, spiritism, healing cults and new religious sects (Pentecostalism and other sects); and other therapeutic responses based on medicinal plants, dance, music, meditation, etc. What is and what should be the position of the official sector with respect to these practices: proscription, control and regulation or ‘laissez-faire’? Is there room in the official medical system for these types of practices? Do today’s universities have any research or teaching function with regard to these medical manifestations of the popular sectors?

And lastly, we must realise that the configuration of medical systems probably have a marginal effect on the health status of the population, as compared with the effects of the social structure, on the control and distribution of medical power, and on the society’s resources as a whole [45]. In other words,

what matters-from the health point of view-is how these resources are distributed and what the accumulation or diffusion of power is within the medical systems or society as a whole, rather than the proportions in which modern and traditional medicine share in a pluralist medical system for a country or given region.

When we are dealing with the health of the individuals of a society, healers and doctors, and-as far as we can assume-deities and saints are all important elements in the integration of social support networks and medical systems for the management of illness and disease episodes. But their contribution to the reduction of morbidity and mortality registered in Third World countries is-as far as we know-relatively small. As several authors have already indi- cated [46,47], and as we have pointed out elsewhere [18], the morbidity profile and the drop in the mortality rate in our countries is largely determined by other factors and not by the density or proportion of healers and doctors.

6. STRENGTHENING PLURALIST MEDICAL SYSTEMS

Abolishing traditional medicine, means not only the proscription of its practices and outlawing its practitioners, but implies above all the suppression of an ideology, an elimination of beliefs and a value system. Although many countries have tried to do this in one way or another, traditional medicine has survived until today in most Latin American countries.

New forms of managing illness and disease have emerged alongside traditional medicine, forming part of the popular explanatory model, and these add to the many therapeutic alternatives used by the population in their health-seeking process.

According to several authors representing different trends, pluralist systems offer special advantages for biological survival and for the solving of psychosocial conflicts or tensions because they represent a gamut of cultural adaptive strategies necessary for survival and the management of disease and illness. We shall now make some propositions for the strengthening of pluralist medical systems in the Andean countries:

(i) The value of knowing more about traditional or folk medical systems is obvious in the potential application of knowledge derived from it to the actual health care system. A global strategy to achieve the participation (not integration) of practitioners of traditional medicine and its technologies in a pluralist medical system could be as follows:

In the first place, the development of local health systems based on the health needs of the population should be promoted, within an overall strategy of decentralisation and participation of all sectors. This local pluralist medical system should be made up of all forms of care relevant to the needs as expressed by the people, and should not only fulfill curative functions of illness, but also exercise the function of healing and caring in the more integral and comprehensive sense of both terms.

Secondly, the participation of healers and other specialists should be carefully negotiated by the representatives of the official sector, practitioners of traditional medicine and the population or their


representatives. These deliberating bodies should hold meetings at the local level to enable the discussion and agreement of a work-plan tailored to each situation and set of problems. Different altema- tive actions can be adopted:

-Intercalating different skills in health care systems: healers could participate as specialists in problems which modern medicine cannot deal with, as for example in the treatment and rehabilitation of alcoholics* in the management of certain chronic diseases such as diabetes or high blood pressure, or in the treatment of mental illnesses or behavioural problems. The training and utilisation of traditional birth attendants for home deliveries and newborn care is another example of co-operation which should be revised and reworked involving the active participation of the traditional midwives.

-Adding or incorporating modern technologies to the treatment administered by practitioners of traditional medicine and other specialists : as for example in the administration of oral rehydration solutions for the prevention of dehydration in cases of diarrhoeal disease amongst infants; or in the early therapeutic management of uncomplicated respiratory infections.

-Promoting research and development of traditional health technologies: a system should be developed for the production and marketing of medicinal plants in order to render them competitive with the pharmaceutical industry and patent drugs in the management of self-limiting illnesses, or in the treatment of chronic diseases which have shown a good response to treatment with plants.

(ii) Knowledge of traditional medicine can also serve to develop new models of clinical practice.

As is known, symptoms vary within each social strata and cultural group. For instance, common complaints such as pain would vary as to how the pain is expressed, where the pain is, as well as in how these symptoms are controlled and suppressed [49].

The information we have today about symptoms and syndromes in the Andean region is insufficient. Traditional Andean medical nosography contains several entities which have to be decodified clinically, such as ‘daiio’, ‘espanto’, ‘ma1 aire’, ‘ma1 de arco iris’, ‘colerina’, ‘pasmo’, and other symptoms such as ‘brainache’, ‘bad liver’, ‘kidney pains’ and others. There is a need to investigate the popular and folk explanatory model for these complaints and culture- bound syndromes. to help discover in them not only the biological but also the psychosocial and cultural meaning, in order to contribute towards an adequate diagnosis and choice of treatment which would be clinically more effective in the curing of disease and healing of illness.

Clinical practice which is based on the conventional biomedical model has a repertoire of interpretative models (biochemical, immunological, viral, genetic, environmental, psychodynamic, pharmaco- logical and others). Symptoms are decodified and interpreted by doctors according to these models, which is why those symptoms which do not ‘fit in’ to

*In the northern coast of Peru, alcoholism is considered as a form of the larger culture bound syndrome ‘daiio’ and is treated successfully by local healers [48].

this repertoire are interpreted as psychosomatic in nature or discarded as non-existent. Several authors have criticised this biomedical approach as reduction- ist and of limited value because it impoverishes the therapeutic function of medicine. Good and Delvecchio propose an interpretative clinical model whose basic aim is the understanding (Verstehen) of illnesses from the patient’s viewpoint, as opposed to the biomedical model whose aim is the diagnosis and explanation (Erklarung) from the doctor’s point of view [49, p. 1791.

(iii) Knowledge of traditional medicine can contribute to the extension of the conventional epidemiological model, not only by procuring better information about the illnesses and culture bound syndromes, but also in the better understanding of how historical, social and cultural data are determin- ant in the appearance and distribution of illness and disease. In recent years, anthropology has undergone important changes, and in the field of medicine it has grown considerably in the understanding of the acquisition and use of beliefs, as well as in the adaptive significance of behavioural patterns in the face of disease [SO, p. 61. Epidemiological and socio- cultural research of diseases and their causes, and of explanatory models and deliberate responses of society to disease, aggression or trauma, are basic tasks in the development of health policies and the construction of a new health system, geared to the achievement of equity in the distribution of health resources in society.

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Healers, Deities, Saints and Doctors: Elements for the analysis of medical systems