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8/11/2019 Langdon Maclennan 1979
1/10
Soc Sd. d
Vol. I3Il. pp.
211
10220
Pergamon Press Ltd 1979. Prinled
in
Grcal 8rituin
0160-7987,79;0901-1l21IS02.00,0
WESTERN BIOMEDICAL AND SIBUNDOY
DIAGNOSIS: AN INTERDISCIPLINARY
COMPARISON
E. JEAN LANGDON and
ROBERT
MACLENNAN1
Department of Anthropology, Cedar Crest College Allentown,
PA 18104, U.S.A.
and
t
IARC, 150 Cours Albert-Thomas, 69372 LYON, France
Abstract-In a household survey of
25
of the Sibundoy population, all persons reporting illness
were interviewed and examined by a biomedical team and a diagnosis was made. Intestinal disorders
were
most prevalent
in
young children, chronic respiratory disorders
in
adult men, and non-articular
rheumatism and chronic headaches
in
adult women. The same persons were independently interviewed
by an anthropologist soon afterwards. The Sibundoy classify illness by manifestations and/or aetiology_
Aetiological
beliefs
include biological, environmental, emotional, social, and mystical 4imensions, which
are explicitly recognized in their diagnostic categories. An illness may have multiple causes, and refer
ence
to mystical causation generally signifies a high level of concern with the illness as well as social
disruption. The results of the comparison between biomedical and Sibundoy diagnosis show that the
dimensions of illness recognized by the Sibundoy in their classificatory system are more comprehensive
in scope than those recognized in
the
Western classificatory system
which
is limited to disease as
such.
INTRODUCTION
Recent reviews
of
the literature in medical anthropo
logy reveal
that
the number of studies in medical
anthropology is increasing rapidly
[1.2].
These
studies most often represent one of two different per
spectives, those
that
focus on disease from the bio
medical perspective
and
those that focus upOn illness
from a cultural viewpoint [1]. Disease is viewed as a
distinct entity with the same symptoms in all indivi
duals.
The
basic ordering premise is biological. Illness
incorporates the beliefs, diagnosis, and treatment of
events of ll health as perceived by those under study.
Several dimensions may serve as ordering principles,
including the social, psychological, supernatural,
and
physical.
Only
a
few
studies have attempted to relate
native conceptions of illness to those of Western bio
medical science, while others have claimed
that
it
is
not possible to compare indigenous notions
about
causes, symptoms, and treatments to the conceptual
grid of scientific medicine [3]. Harley, a medical doc
tor, attempted such a comparison several years ago
[4].
Lewis, a mec;lical doctor and anthropologist, and
Jansen, an anthropologist cooperat ing with a phys
ician. have more recently made significant contribu
tions to this
area
[5,6]. Perhaps the largest.
numbers
of such studies are found in the literature
of
epidemio
logy
of mental health. For example, Foulks, an M.D.
and anthropologist, has studied arctic hysteria from
biological, ecological, and social perspectives
[7].
Such comparisons of native systems with Western
biomedicine are difficult, for they require the knowl
edge
of two highly specialized fields, anthropology
and medical science, utilizing theories, methods, and
goals that are often divergent.
The
research cited
above have been conducted by either individuals
t
The
history of exploitation of the Sibundoy Indians
on the part of the white settlers in the
valley
is documented
by Bonilla [11].
specialized in both fields or by anthropologists and
physicians cooperating closely.
This
paper reports an
interdisciplinary study conducted by an anthropolo
gist
and
physician
among
the Sibundoy Indians of
Colombia. t is concerned with all prevalent illness
during the period of research (as perceived by house
hold members) and compares Western biomedical
diagnoses with those of the Sibundoy. The focus is
upon
the possible dimensions of comparison of the
two systems of medicine. The cultural perspective of
Sibundoy medicine is described in depth by Seijas
[8-10].
The study here is not a duplication of her
material
but
an extension of aspects related to our
purposes. Those who wish more information from the
cultural perspective should consult her publications.
CULTURE AND ENVIRONMENT
The Sibundoy Indians (some 2000 persons) occupy
part of a small highland valley 2200 meters above
sea level in southern Colombia.
The
valley is also
occupied by a large white population (approximately
persons) and another Indian group, the Inganos
(3500-4000 persons) [9]. Although each group tends
to remain apart from the others, there is significant
interact ion between them, particularly in economic
matters.
The
non-Indian
population
dominates the
local economy and
has the best farmland.t The
Sibundoy have become acculturated in many ways
as a result of schooling, financial transactions and
other activities with the whites.
All
but a few elders
are fluent in Spanish, yet they bave continued to
maintain separate identity through traditional lan
guage in the home (Kamsa), traditional c1qthing and
separate residence.
The climate of the valley is cool (mean 16.2C and
exceptionally humid, particularly during the heavy
rainy season from June to August when the Sibundoy
feel especially vulnerable to damp coolness of
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2 2 E JEAN LANGDON n ROBERT MACLENNAN
tbeir environment. They live in the marshlands
of
the
valley where the gardens are frequently flooded and
the paths deep in mud.
As
will be seen, the dampness
and
cold are perceived by the Sibundoy as causes
of
a significant number
of
disorders. .
The
Sibundoy are a horticultural group whose
staple crops are maize an d beans, although taro is
also important. Most raise chickens, ducks
and
the
native guinea pig; and some
own
cattle.
The
econo
mic
an d
medicinal use
of
plants are described by Bris
tol [12-16].
The Sibundoy have several medical
and
paramedi
cal services to choose from in the event
of
illness. The
Ministry
of
Public Health supports four bealth
centers in the valJey
an d
jointly supports a small hos
pitaJ with the Catholic Church. Each health center is
staffed by a practical nurse
an d
attended by one
of
the
two physicians in tbe valley. Consultations were
approximately SO.l5 (U.S.) in 1970, a minimal fee for
the Sibundoy. Several pharmacies provide a major
source
of
medical services, for the pharmacists give
free
medical diagnoses
and
are able to dispense
most drugs without a prescription. Another important
source for the Indians is
a white curer
curandero
who is regarded more highly than the physicians by
most of the Sibundoy. Prior to him, a Catholic priest
with substantial medical knowledge was a major
source for consultations until his death in the
19605.
.
i\mong
the Indians, there are two sources for the
dIagnosis
and
treatment
of
illness: heads
of
house
holds and the shamans. Most Sibundoy have knowl
edge
of
herbal remedies
an d
their gardens include
several herbs
an d
plants for the treatment
of
common
and
minor illnesses.
Th e
head
of
the household plays
a key role in administering treatment to family
members drawing
upon
these herbs
an d
also consult
ing the local pharmacist when necessary.
The
shamans have received formal training in the
use
of
herbal remedies
an d
the ingestion
of
the hallu
cinogen biaxii (Genus Banisteriopsis
t
is
of
major
importance in diagnostic
an d
therapeutic procedures
for illnesses believed to have supernatural causes.
Seijas' investigations revealed
that
the conceptual
scheme
of
Sibundoy aetiology is dichotomous: dis
ease can be attributed to mystical
or
non-mystical
causes [8]. This duality is similar to
that
pointed
ou t
for other groups throughout the world [17-19].
In most cases the Sibundoy are concerned with only
the immediate explanations
of
illness, which is attri
buted to some natural force, such as exposure to the
cold, lack
of
resistance, and such. As long as the con
cern with the illness remains' at this level, various
remedies
and
any of the medical practit ioners may
be utilized by the Sibundoy. However, when
an
illness
does
not
respond to treatment
or
exhibits unusual
symptoms, it is suspected of,having a mystical cause,
such as sorcery
or
evil wind .
so, the native sha
man must be called
upon
to perform the necessary
ritual in order to determine
and
counter the mystical
cause. During the ritual, he drinks the hallucinogen
Banisteriopsis
From
its visions, he interprets the exact
cause an d attempts to remove it.
The
dichotomy of mystical
and
non-mystical as de
scribed by Seijas does
not
imply that the Sibundoy
themselves recognize such a distinction.
t
signifies,
however, two levels
of
concern with regard
to
illness.
The first involves mild concern
and
a sense
that
the
iUness can be cured without the aid
of
a haman.
The
second involves more serious concern with the
outcome
of
the illness and a seeking
of
the ultimate
cause of the illness, the why
of
the event.
The
answer is most often found in the social
and
super
natural world in which the patient has caused
or
ex
perienced some disruption with his
or
her fellow
humans
or
with the spirit world.
METHODS
Biomedical
Two representative areas in the centre of the Sibun
doy hamlets were selected
and
all households were
visited by the medical team. There were
101
house
holds comprising 507 persons (25
of
the Sibundoy
population). Prevalent illness was first ascertained by
interview
of
adults
an d
older children. Two senior
male medical students then did a medical examin
ation (in the ill only) limited
to
a detailed history;
physical examination; blood haematocrit; urine sugar
and protein and
microscopy
of
faeces in selected
cases. Most
of the
ill were subsequently examined by
the physician
R M ~
especially where the diagnosis
was uncertain. Free treatment was given
bu t
the diag
nosis was
not d i s c u s ~ d at
this stage with the patients.
Anthropological
Within a few days the households
of
the ill were
visited by
an
anthropologist (EJL) who did
no t
know
the biomedical diagnosis. Directed interviews were
conducted with
an
adult member
of
the household
and or the person reported to be ill by the biomedical
team. Each informant was asked the name
of
the ill
ness, causes, history with emphasis on onset, symp
toms,
and
any treatment, including remedies. Inter
views were conducted in Spanish,
bu t
diagnoses were
recorded in
Kamsa
wherever possible.
RESULTS AND COMMENT
Biomedical diagnoses
Medical diagnoses are given by sex an d age in
Table
1.
Diarrhoea is the most prevalent illness in
both sexes, especially in young children (30.6
of
children under 5
yr).
Chronic respiratory disorders
rank second, are more frequent in adults an d a little
higher in men 15
yr an d
above)
than
in women
(12.6
an d
8.9 respectively).
One of
these was
almost certainly tuberculous
bu t
a definite diagnosis
could
not
be made due to the failure
of our
X-ray
equipment
an d
the refusal by the pat ient
of
an offer
of
free travel to the nearest X-ray facility. Non-articu
lar rheumatism (11.5 )
an d
chronic headaches
8 . ~ 1 o
were prevalent in adult women.
Th e
latter disorders
were rarely seen by
on e
of us (RML) in a large general
hospital involved in primary medical care in the Wes
tern highlands of New
Guinea
in 1957, although the
physical environment was similar.
Th e diagnoses in Table 1 are based
on
a history
of
symptoms
and
a careful physical examination. This
has inevitably limited
the
specificity
of
diagnosis. For
example, biliary colic was diagnosed in three males
on
the basis
of
a characteristic description of the pain.
Presumably this was
due to
gallstones which are not
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4
E. JEAN LANGDON
and
ROBEIlT MACLENNAN
universe. It is not unusual for an illness, particularly
an acute or chronic one, to be attributed to several
causes. For example, a body
in
a state of weakness
through loss of
blood
is
predisposed to contracting
another illness. In this case, weakness
is
used as both
an illness and a cause, depending on the circum
stances. The psychological states of fright or sor
row work
in
similar
ways.
Both are illnesses
in
their
own right and also may be predisposing conditions
for other illnesses.
ur
findings support Seijas in that
etiology is dichotomous [8]. In the Sibundoy
view,
the dichotomy in the causes of disease is between
those causes which can be cured by any method of
healing and those which require the special ritual of
the shaman. The latter class are termed as ultimate
causes, for they relate the patient s illness to the social
and cosmological world giving an explanation of the
why of the
illness.
Foster has termed medical sys
tems with this kind of aetiological beliefs as persona
listic in which illness is believed to be caused by the
active, purposefu l intervention of a
sensate
agent who
may be
a supeniatural being ( a deity or a god), a
nonhuman being (such as a ghost, ancestor, or evil
spirit), or a human being a witch or sorcer) [21].
The patient
is
a victim of aggression or punishment.
As
mentioned earlier, this kind of cause represents a
level of serious concern over an illness and the specu
lation about it is begun only after several attempts at
healing the illness through other
ways.
The persona
listic system is complex, for two or more levels of
causality can be distinguished, and these levels must
be taken into account when curing.
Illnesses recognized by the informants
fail
into two
types: single-symptom illnesses and symptom
complex illnesses . the
first
type, the term describes
the major and usually only symptom, such as pie hin-
chado (swollen foot . The Sibundoy use these ad hoc
terms to name or identify any bodily ache or pain
that occurs. Simultaneously occurring symptoms in
different parts of the body are often diagnosed as
dif-
ferent single symptom illnesses rather than as mani
festations of one disease, although patients may
believe the ailments to be related (one may cause the
other). In the second type, the term implies to a set
of culturally recognized symptoms. The illness is
recognized as having several manifestations. Many of
the illnesses of this kind divide into sub-classes, and
the diagnosis in these cases depends on the symptoms
present and the presumed cause.
The listing of folk illnesses below reflects the order
ing principles utilized by the Sibundoy. The most pro
minant one is anatomy, and the list reflects those ill-
nesses that are perceived by the Sibundoy as having
common locations. Some have a cover term used
by
the Sibundoy, such as
pu/nwnes
or
lungs. Others do
not, and we have substituted English terms. The link
ing of the disorders, regardless of the cover term, re
flects the Sibundoy classification. The exception to
this are those under miscellaneous , which includes
the illnesses only reported one or two times in the
sample. The order of the categories, on the other hand
is a reflection of the order of prevalence in which
these illnesses
were
reported. The second ordering
principle refers to illnesses classified by aetiology. An
illness category may reflect both. So/tura (diarrhoea)
is
classified as a kind of stomach ailment. The sub-
classes of so/tura are classified by cause, such as from
worms or
fever.
A few diseases are not classified
by
body location, but primarily
by
cause. These include
those generally attributed to emotional states and
mystical causes.
ILLNESSES CLASSIFIED
BY
ANATOMY
AND AETIOLOGY
Est6mago;Stomach
Almost all abdominal disorders are considered
d r
de
eSlomago (stomach ache), the illness most
often reported. It is a symptom-complex illness which
divides into various sub-classes, which may be either
single-symptom or symptom-complex.
D r
de esto-
mago sub-divides into several single-symptom-iIlness
and one symptom-complex, sollura (diarrhoea), which
is
further classified
by
aetiology into: lombrices
(worms), solitaria (tapeworm), de fiebre (of fever , del
frio (of cold), de golpe (of a blow), and de mal viento
(of evil air).
Main type of soltura diarrhoea . Lombrices (intes
tinal worms) is the most common sub-class of so/tura
(Table 2 . For the Sibundoy, intestinal worms are a
natural fact of life. They believe that everyone suffers
from them from time to time and must be purged of
them. In cases of children, they often attribute the
cause to eating too many sweets. Although they know
of herbal remedies for lombrices, they rely more
heavily on patent remedies alone or in combination
with herbs. The set of symptoms for diarrhoea due to
worms includes yellow or brown diarrhoea, lack of
appetite, and a growling stomach. Most decisive
for
the Sibundoy, however,
is
the passage
of
worms after
a purge. In their absence the illness
is
reclassified as
another typ of so/tura.
Other types of soltura. These are less prevalent
(Table 2 than lombrices. Soltura de fiebre (of fever
is generally yellow, white, or brown. It is caused by
fever
one type of which corresponds to high body
temperature and causes diarrhoea. In the other type,
fever
is
believed to be localized
in
some body part;
thus, the fever of a diseased liver may cause diarrhoea.
It has also been said that the
fever
from
/ombrices
causes diarrhoea. Soltura del frio comes from the cold.
Cold generally refers to the climate. Many informants
said that during the winter, almost all diarrhoea is
from the cold. Its colour is generally green, possibly
with blood. However, the Sibundoy also recognize
that the presence of blood may be a result of a hard
blow de olpe causing bleeding. Diarrhoea with
blood is also classified by some as disenteria, a sub
class of dolor de estomago, but not of so/tura. So/tura
de mal viento is mystically caused from an
evil force
in the air. Its symptoms are discussed below with
other mystically caused illnesses.
Symptoms of soltura. Symptoms cited by the Sibun
doy that accompany all classes of soltura are vomit
ing, stomach-ache and fever. So/tura can cause other
complaints, such as estomago empachado (swollen
stomach), dolor de cabeza (headache), mareo (dizzi
ness ,
debilidad (weakness), or co/ico (colic). Diarrhoea
with blood is often considered a major cause of debili-
d d
and mareo, for they believe that an individual s
quantity of blood is limited and that loss of it will
cause weakness or debilidad.
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Table 2. Sibundoy diagnoses by
e
and age
Male
Female
11 18
21 8 58
16
14
29
11
70
G-4 5 14
1>-44
45
Total
G-4
5-14 1>-44
45
Total
5
7
2
3
17
5
4
2 11
3 3 I
7
3 2
2
6
I
1
2
4
4
1 1
1
3
5
1 7
9
3 13
3
1 4
3
4
2
1
4 2 6
1 2
1 1
1
2
1
1
1 1
1 1
2 2
No. persons interviewed by anthropologist
Lombrices soltura
Soltura all others)
Dolor de estomago
Es/omago empachado
Solitaria
Vomi/o
Salida de /rasero
Colico
. Disenteria
Reumatismo
Mal
de
pulmanes
Mal
de
riiiones
Mal
de higado
Bllis
OIanda en
la boca
Granos
Sarna
De la
ma/riz
Nervios mareo
Dolor
de
cabeza
A/aques
De
cerebro
de mente
Fiebre
Gripa peste
Debl/idad
Dolor de eintura
Piquetes de corazan
Ardor en la espalda
Paperas
Venas amorliguadas
Orina
par
la
noehe
Tifo
Pique/es en el
pecho
Lovanillo
Tumor
Pie hinchado
Pie aeM/ado
Qlher minor conditions
Mal aire
Espanto suslo
Total
2
88
3
2
2
10
4
3
6
3
2
3
5
2
1
4
5
16
6
1
1
3
4
5
3
2
1
1
4
1
95
Reumatismo/
Rheumatism
Reumatismo rheumatism) is common in adult
women Tables I and
2 .
The Kamsa word for rheu
matism
is
sesna sokan sick from the cold ).
Any
ache
in a bone is usually diagnosed as rheumatism; the
most decisive symptom is the feeling of the bones
being chilled: e.g. one woman had pain and pricking
sensations
in
the chest, but since her bones ached
when they were
coli
she diagnosed her illness as reu-
matismo.
The major causes
for
rheumatism are cold
and humidity if a child
is
not kept dry,
he
will get
rheumatism ) and a weakened state
e.g.
the post-par
tum period of
forCy
days). One woman injured her
leg
and from the cooked blood she contracted reu-
malismo when she had to wade in cold water during
the winter. Two cases of reumalismo were attributed
to mystical causes: suslo fright) and sorcery.
Pulmones/Lungs
Mal de pulmones bad
in
the u n s ~ referring to
chest ailments, is most frequent among adult
men.
Several sub-classes are recognized: los seea dry
c o u g h ~ lOs
ferina coughing with blood, whooping
c o u g h ~ tos asma s t h m ~ tos vieja a deep old cough),
and pulmones
permanente
permanently damaged
lungs). The symptoms reported for lung disorders are:
cough dry or with blood); fever; pricks, pain, or
burning
of
lungs, back, arms and shoulder; and
breathing difficulties. In relation to the last symptom,
many first reported that they suffered from debilidad
and then specified pulmones.
Chest disorders are most commly attributed to the
cold or to work, particularly in men who cited carry
ing heavy loads
or
working too long
in
the drainage
canals, a communal task which each man must per
form. Also, if a man is working in the sun and it
begins to rain,
he
is susceptible to pulmones and one
informant said that the sweat mixes with the blood
and causes pulmanes if his clothes are not washed
after such circumstances. Other causes cited are a
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6
E JEAN LANGDON and R08EItT
M CLENN N
blow in the chest
and
weakness due
to
lack
of
blood.
One patient claimed that mal de rinones will cause
pulmones.
Rii lones/Kidneys
Riiiones (kidneys), limited exclusively to adult males
in this sample, is characterized by pain in the back
or waist. Its causes are similar to those of
pulmones:
work, cold or a blow.
Higado/Liver
l
del higado (liver) is also believed to be caused
by work. although the major cause cited
is
too much
liquor
to
rink especially during communal work
projects mingas) on the canals. A man may pass out
and the heat from the sun is believed to damage the
liver. One case was attributed
to
espanto
or
fright.
The symptoms are: fever, a bloated s tomach or
an
ache in the liver (the centre
of
the chest), olanda
(thrush) in the mouth, yellow complexion, headaches,
and the irritability from heavy foods such as oil, meat,
corn beer or
corn
spirits. Higado can cause bilis (bile).
Skin lesions
Granos
and
sarna are lesions
that
appear on the
skin. Although believed to be caused by the rainbow,
the exact causal relationship between skin disorders
and the ra inbow was not ascertained, al though
we
suspect that it is related to spirits. One case was attri
buted to mol aire (evil air).
Matriz/Gynaecological
Gynaecological disorders, de la matriz (of the
uterus)
or
de vientre (of the womb) have two sub
classes: desarreglo (irregular period)
and
hemorragia
(hemmorrhage). In both, the menstrual period is said
to occur every two or three weeks;
but
in the laUer
heavy bleeding and severe pains occur. According to
a local hospital nurse there is a high incidence
of
menstrual problems
among
the women,
but
they
refuse to be examined by a male doctor and prefer
the woman curer in the valley town of San Francisco
to
treat such problems. Thus, it is probable
that
the
prevalence
is
higher
than
reported in
our
sample,
since the medical team was all male.
Gynaecological disorders
can
produce debilitkul
due to lack
of
blood and consequently mareo (dizzi
ness) and headaches.
The
main cause is desmando de
dieta,
i e not obeying the post-partum dietary restric
tions.
Cabeza/
H
ead
Marco. Mareo (dizziness), a complaint most com
mon
among adult women, is also called nervios
(nerves).
The
symptoms
are
headache, dizziness,
weakness, and being in a state of
susto
(fright). In
such a state, the person is easily startled by any
sudden noise or movement
and
often feels cold chills.
The major cause of nervios or mareo is believed to
be debilitJad. lack of blood or food. Fright was cited
as the cause of one case of
nervios.
Ataques. Ataques refers to attacks of unconscious
ness, accompanied by pains
and
palpitations in the
heart. There are two classes: de nervios (of nerves) and
de pena (of sorrow). Ataques de nervios occur in per
sons also suffering the symptoms of nervios. Ataques
de pena, caused by sorrow from the death of a loved
one worries, or fear, occur without the symptoms of
nervios. One patient claimed that he had suffered from
ataques ever since sorcery caused him
to
fall from a
bridge.
Two mental disorders
are
recognized: de cerebro
(described as forgetfulness)
and
enferma de
la
mente
(illness of the mind). The patient in the latter case
had
been in a mental clinic in Pasto. His relatives
reported
debilit u
due to lack of food
as
the cause.
ild disorders
Fiebre (fever), gripa, peste (common cold, flu) and
debilitkul (weakness) are terms used for mild states
of illness which are believed to make a person vulner
able to other
diseases.
The
onset
of many
chronic
or severe illnesses are attributed
to
the time when
the patient was weak
or
worked while
half
sick
medio mal) with jiebre, gripa, or peste. Cold weather
is cited as the cause of the last three.
Miscellaneous disorders
Most of the less
common
illnesses
are
single-symp
tom and
the causes
are
work. weather,
or
some
physical blow or accident. Those attributed
to
work
or weather are dolor de cintura (pain in the waist),
piquetes de corazon (pricks in the heart), ardor en
la
espalda (burning in the shoulder), paperas (lumps
forming in the veins
of
the neck), venas amortiguadas
(deadening of veins), and orina por la noche (bedwet
ting).
The
last is caused by the cold when a child
begins wetting the bed
around
5
or
6
years with no
previcus history
of
it.
Tifo (also known
as
pelador), although occurring
only once in our sample, is a symptom-complex ill
ness with an extremely high fever, severe headache,
and
a loss of hair
due
to the fever. The patients in
the sample complained principally
of
a chronic head
ache. Although they attribute its cause as the cold,
it is evidently a contagious disease (possibly typhus)
which has caused local epidemics.
Piquettes en el pecho (pricking. sensation in the
chest), lovanillo (lump), tumor (tumour), pie hinchado
(swollen foot),
and
pie achatado
(flat feet) are attri
buted
to
a blow or
an
accident. In the last two cases
the pregnant mother
had
received a blow in her
stomach in the vicinity of the child s foot. Other
minor conditions included general pains, burning of
the arms and shoulder, infected laceration, deafness
and
poor
vision.
ILLNESSES CLASSIFIED BY AETIOLOGY
Malaire
(evil air) and
espanto
or
susto
(fright) are ill
nesses classified by aetiology indicating the syndrome
falls primarily within the level of personalistic causa
tion
and
requires shamanistic treatment. l aire
comes from some unidentified supernatural agent in
the air, while espanto involves a frightening experience
that
mayor may not C?me from a supernatural agent.
Like mal aire, however, it requires the indigenous
ritual treatment
performed by a specialist in super
natural curing, preferably a Sibundoy shaman.
Although these terms specifically indicate a super
natural cause. illnesses classified by manifestation
may also be suspected to have a mystical cause. Thus,
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Western biomedical and Sibundoy diagnosis 7
certain cases diagnosed as
reumatismo granos and
others previously described were attributed to sor
cery 1M aire and espanto.
The
prevalence
of
illnesses attributed to mystical
causation is low, representing 5.4
of
the total
number
of
illnesses reported
and
7.8
of
the total
number
of
patients. This small sample supports the
observations made by Seijas regarding the relative
distribution of mystically caused illnesses by sex
and
age [10]. Mal aire is limited
to
children, and three
of the five cases stemming from
espanto are
children.
In the other two cases, both patients were in a state
of
debilidad
when they suffered the fright.
On
the
other hand, in our study witchcraft only affected
adults.
Although the prevalence diseases requiring ritual
healing in our sample
is s m ~
this does not indicate
that the Sibundoy
are
not concerned with mystical
causes. Since they
are
generally associated with the
more serious
and
chronic cases, it is probable
that
the Sibundoy are
more
concerned about these dis
eases thl n with the
common
illnesses. Also, the preva
lence of these diseasees is probably underestimated
in this sample due to the reluctance of the Sibundoy
to discuss such beliefs with non-Indians.
Much of
this
stems from a mistrust
of
whites and the desire to
maintain a cul tura l barrier. Only informants with
whom good
rappon
had been established
prior
to
this sur.vey reported mystical causation. Furthermore,
since Multiple causation is common, it is probable
that many diseases
reponed
as having natural causes
might also have mystical ones which were not dis
closed.
Certain symptoms are
associated with mystical cau
sation, in particular
mal aire.
In children, chronic
and/or green diarrhoea ,
or
excessive crying, es
pecially at night, may indicate mal aire or espanto.
Among adults, headache, fever and swelling
of
the
body or limbs are symptoms of mal aire. However,
these symptoms are neither necessary nor sufficient
criteria for diagnosis of supernatural causation. t is
generally the presence of unusual symptoms or severe
illness which leads
to
suspicions of mystical causation.
The unusual
symptom
may occur
in
addition to the
expected symptoms,
at
onset
or
following treatment.
One case demonstrates this sequence particularly well.
Awoman became seriously
ill
Her husband, having exten
sive Imowledge of herbal remedies, attempted the first
treatment. Then
he
resorted to the drugstore and a white
curer
who prescribed a combination of herbs, baths, and
patent medicines.
As
her situation beca,ne more serious,
she
was taken to the doctor
in
the valley
who
diagnosed
the
disease as cancer or tuberculosis.
She
was hospitalized
for several months
in
the valley's small hospital, and the
doctor attempted to convince the
family
that she should be
taken
to a larger hospital
for
more thorough examination
and
treatment. The woman returned home, remaining bed
ridden for a few months until the family was able to trans
port
her
to the regional hospital. However, the doctors
there
said that she
was
too
far
advanced and sent her
home. The
family
then called on a local shaman and gath
ered for the hallucinogenic ritual. His diagnosis was sor
cery of such strength that it was incurable. At this point,
the family gave up in despair, recognizing the gravity of the
illness. Shortly thereafter, her coffin and a cross
were
con
structed
in
anticipation of her death, which occurred
six
months later.
S.S.M. 13/3B 0
Any disease with a sudden onset, such as a cold chill
or
sudden fever,
is
usually believed to have a mystical
cause. A child may suddenly wake up screaming or
cry when sleeping. Frightening experiences accom
panying the illness
or just
prior to it may imply mysti
cal causation. However, if the illness
starts
with
fiebre
tranquila calm fever another cause is suspected.
The response of the patient
to
treatment is perhaps
the most decisive indicator
of
mystical causation.
When
illness occurs, a member
of
the household diag
noses the disease and applies a remedy, drawing from
his knowledge of herbs and patent medicines. In the
case of failure, he may rediagnose the disease
and
try again, or he may resort
to
any of
the
medical
or
paramedical services in the valley.
treatment
continues to be unsuccessful, concern with the illness
increases and the Sibundoy begin to ask
what
is the
ultimate cause that accounts for the persistence of
the disease. At such a time, a
shaman
is requested
to
perform the hallucinogenic cur ing ceremony
to
diagnose
and
counteract ultimate cause,
making
the
patient receptive to herbal
or
patent remedies.
For
adults, the cause often stems from some disruption
in social relations, thus introducing the social dimen
sion in Sibundoy illness classification.
Comparison biomedical n Sibundoy diagnoses
Out of 507
persons in the households visited,
176
reponed illness
to
either the medical team or the
anthropologist.
Of
these 106 persons had both a
medical examination
and
an
anthropological inter
view with
an
additional
49
medical only and 21 an
thropological only. The differences were because not
all medically examined persons could be interviewed
by the anthropologist and some illnesses were first
reported to the latter . The additional cases have a
similar
pattern of
illness and
are
therefore reported
together with other cases.
The Sibundoy diagnoses in the 106 persons who
also had a medical examination are given by biomedi
cal diagnosis in
Table 3. This is
a
comparison of
two
classifications of illness in the same individuals. Many
categories show a close correspondence, due
to
the
similar descriptive
nature
of both classifications. Both
are based
on
a number
of
different axes rather
than
only one. Bodily location and cause, as noted, are
the two most
important
factors in the Sibundoy clas
sification and they
are
also
important
organizing fea
tures in the biomedical.
One
important difference,
however, is that whereas most Sibundoy illnesses are
of
the single-symptom type, a biomedical diagnosis
may
group
several symptoms as a complex related
to specific underlying cause. This is illustrated by bili
ary
colic in
Table
3. However, the biomedical diag
nosis may be no
more
than descriptive in the absence
of a diagnosed cause, e.g. chronic enterocolit is
and
chronic headache, where the Sibundoy diagnosis may
be
more
specific , perhaps
due
to their greater will
ingness
to
diagnose specific causes.
The diagnosis made in Western biomedicine often
depends
on
the context. A surgeon confronted with
acute abdominal
pain
will classify patients into those
to
be
treated
by
urgent surgery and those no t
to
be
so treated. Despite this therapeutic axis,
an attempt
will
be
made to
localize the disease (anatomical axis)
and assign if possible, a cause (aetiological axis). The
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8
E
J LANGDON
and ROl tT MAClENNAN
Table
3
Comparison of biomedical and Sibundoy diagnoses
Biomedical diagnosis
Oral monilia
Biliary colic
Acute entero-enteritis
Chronic entero-colitis
Abdominal pain
Head cold
Acute bronchitis
Chronic bronchitis
Cardiac murmur
Cardiomegaly
Vaginal discharge
Menorrhagia
Lipoma
Scabies
Scattered pustules
Non-articular rheumatism
Muscular atrophy foot
Edema foot
Chronic headaches
Disorder of mood or behavior
Eneuresis
No abnormaJity detected
Number of
persons Sibundoy diagnoses
I
Olanda
I
3 Dolor de estomago I; higado 2
6 Diarrea 2; lombrices 2; other soltura 2
8 Ataques I; lombrices 12; other soltura
13
3
Dolor de est6mago
1;
lombrices
I;
1 Gripa peste 1.
2 Gripa peste 1; pulmanes
I
14
Mareo I; fiebre 1; pulmones
I
Higado
I
1
Reumatismo
1
1
Matriz hemorragia
1
2 Matriz desarreglo 1; hemorragia 1
1
Lobanillo
1
3 Granos 3
I
Sarna
1
13 Reumatismo
12;
ardor de espalda
I
1 Pie achatado I
1
Pie hinchado
1
7
Ataques
2;
dolor de cabeza ; debi idad
1;
mareo ; nervios mareo
3;
tifo
1
2 Nervios mareo 2
1
Orina por la noche
I
3 Estomago empachado 1; lombrices 1; soltura 1
biomedical diagnosis may become more specific
fol-
lowing a physical examination, the use of ancillary
tests such as microscopy and radiology, surgical inter
vention and/or response to treatment. The final diag
nosis
is
the one considered most probably in the basis
of the evidence available.
Sibundoy diagnoses also use initial diagnostic cate
gories based on symptoms. The treatment reflects a
pragmatic and basically empirical process that has
been well documented for other cultures [21-25]. A
provisional diagnosis
is
first made by members of the
household based on the symptoms present and any
significant features in the onset of illness that might
give clues as to its cause. A treatment found to be
successful for a similar illness in the past
is
first
sougHt. Thus, like Western biomedicine, the primary
axis of diagnosis
is
therapeutic. Remedies may include
herbs, patent medicines and modern drugs. The
Sibundoy usually begin with herbs and if no response,
proceed to other remedies, and health services offered
in the valley. Unsuccessful treatment leads to a revi
sion of the diagnosis as well as treatment.
In addition to
the
various persons consulted,
sources of information about disease and medicines
include advertisements on the radio most households
have a transistor radio) and in printed pamphlets
which often list the symptoms of common ailments
and suggest an appropriate brand-name drug treat
ment. Such advertisements use folk medical termino
logy and encourage self diagnosis and treatment. The
Sibundoy have also incorporated ideas on causation
from these sources. Several men, including one sha
man, produced notebooks describing the effects of
specific patent drugs used previously for various
self-
diagnosed illnesses. Thus, it can be concluded that
at least within the initial level of concern and treat
ment, the Sibundoy alter both beliefs and behaviour
based upon an objective analysis of the reaction of
an illness to a particular treatment. Moreover, sources
of change in their belief system come from the non
Indian culture. A similar process of change has been
reported in Ecuador [26].
f
the different treatments
fail
in alleviating the
symptoms, the Sibundoy will seek to discover the rea
SOil
why the illness does not respond to treatment
aetiological axis). Unlike Western biomedicine, how
ever, the search for the cause at this point indicates
both increasing concern for the outcome of the illness
and the questioning of the ultimate why of illness. f
the illness is of a serious nature, has unusual
and
severe symptoms, or fails
to
respond
to
a series of
treatments, then mystical causation is suspected.
f
so, it
is
believed that
only
the native shaman can cure
this ultimate cause, but his participation in the case
does not exclude the use of other remedies or even
other medical specialists prior to or after the ritual
curing ceremony. Beliefs about causation and treat
ment on the mystical level are less subject to empiri
cal testing. The secret knowledge of the shaman
is
used to counteract the ultimate or underlying cause
of illness rather than treat the manifestation as a dis
ease. The shaman assists understanding of the mean
ing of the illness within a wider socio-cultural context.
In this respect, the etiological dimension becomes sig
nificantly different from that of Western medicine.
t
is
in dimensions of causation that the greatest
differences appear between the two systems. The
Sibundoy,recognize several dimensions of causation
not accounted for in the biomedicine.
For
common
and easily cured illnesses, causes come from forces
in the natural environment, a run-down physical
state, or an emotional state. The causes attributed
by the Sibundoy were further analysed for two com-
, mon diagnoses. In 28 cases of chronic enteritis, 12
were attributed to the physical environment includ
ing
10
to the cold),
six
to food or drinks, nine to
unknown and one to mystical causes.
Of 17
cases
of chronic headache, six were attributed to the physi-
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Western biomedical and Sibundoy diagnosis
219
\ I
environment,
and
three each to food
or
drink.
work, lack of resistance. and mystical causes. More
than one cause was often assigned per individual. or
the more serious illnesses, emotional
and
social
dimensions of illness are recognized
by
the Sibundoy.
As found by Seijas and reaffirmed by this study.
chronic and serious illnesses in .adults tend to be attri
buted
to
sorcery as the ultimate cause [10). These
cases implicate others
as
wishing ill toward the
patient and place the ultimate cause of illness within
the rea lm of social relations. Moreover.
attribution
of mystical causation
is
symbolic
of
the social disrup
tiveness
and
seriousness of the illness. Illness is a
social event, affecting
others
as well as the patient,
and this
is
particularly clear in those illnesses to
which some ultimate explanation is sought. Thus,
Sibundoy illness terms
as
found in this s tudy
not
only
reflect etiological beliefs concerning the physical.
emotional, and social
components
of illness, but also
lay signal the seriousness
of
the illness
in
certain
cases.
The
diagnostic nomenclature
of
Western medicine,
on
the
other
hand, is largely a taxonomy by patho-
logical
anatomy
[27]. I ts basic premises of causation
rest in biology and physiology. The capacity
of
emo
tions to effect the body is recognized to a limited
.extent in psychosomatic disorders, while the illness
Usto
or fright directly recognizes the emot ional
dimension. Moreover, in Western medicine, the social
aspects and consequences of disease are not included
in biomedicine as significant dimensions in disease
classification and diagnosis. although it has been sug
gested by abrega
that
this should be the new direc
tion in the
study
of disease [2).
A striking feature of the Sibundoy medicine is the
close resemblance
of
symptoms
and
aetiological
beliefs to olombian folk medicine [28-34).
or
example. diarrhoea is classified by the colour of the
excrement
[l
31 32]. and is believed
to
be caused by
cold weather, fever,
or
from worms [28). As with the
Sibundoy. physical environment has been cited in
other
studies
as
a cause
of
gynecological disorders;
hard work as a cause of lung disorders; lack of
blood
and
lack
of
resistance as causing susceptibility to
other illnesses [29, 30-33). Thus the Sibundoy disease
classification and concepts of natural causation in
general resemble those
of olombian
folk medicine
rather
than
forming a distinct
and
isolated indigenous
system. This is
not
true, however. for the many of the
personalistic causes recognized nor for the
method
of
treatment for such causes which
is
specific to the
Sibundoy and nearby indigenous groups.
The
many
differences may result from the role of treatment in
Subundoy diagnostic procedures, in which they con
sult a great variety
of
non-Indian medical practioners
for relief of symptoms not attributed to personalistic
causes.
This
suggests
that
they
are
not only adapting
western and folk medicines
as
used by the general
populace, but tha t they are also changing their medi
cal beliefs as they utilize non-indigenous cures.
DISCUSSION AND CONCLUSIONS
Although
none
of
the illnesses was severe
or
life
threatening at the time. the diagnoses were made in
a context similar to that of much
of
primary medical
care in the tropics. The medical team of physicians
and students were thoroughly trained in clinical medi
cine. and hence may have achieved more accuracy
than
is
usual in such situations
in
rural areas. Never
theless. the diagnoses listed in Table I are not specific,
especially with regard
to
aetiology. Thus, the pleural
effusion
and
some
of
the chronic bronchitis cases
may
have been tuberculous, and the specific bacterial or
parasitic causes
of
the many cases
of
chronic entero-
colitis were not elucidated.
The
International Classifi
cation of Diseases is not especially suitable for the
diagnoses of this survey, but nor is
the
International
Classification
of
Health Problems in Primary Care
[35J recently developed in a number of Western de
veloped countries.
The
modern
pharmacopoeia
con
tains a large number of drugs which require specific
diagnosis. This is often impossible in rural primary
care. especially in
the
tropics, and the usual solut ion
has been to base treatment
on
knowledge of the local
disease pat tern in a series
of
patients who have been
more extensively investigated.
The comparison between Western biomedicine and
Sibundoy medicine has revealed that Sibundoy medi
cine
is
a more comprehensive explanatory system
than western biomedicine. and that this greater com-
prehensiveness is reflected in disease categories
and
diagnosis. Although diagnosis of most common and
mild illnesses is largely restricted to the symptoms
and therapeutic goal. diagnosis and aetiological
beliefs utillized in serious illnesses place the condition
within the total social and
supernatural
universe of
the Sibundoy. On the other hand, Western biomedi
cine diagnosis and treatment remains largely restric
ted to diseases as such. Studies in social epidemiology
have revealed
that
disease is a function of social.
economic, cultural,
and
ecological factors. Yet these
findings have not been incorpora ted into the axes of
diagnosis.
Acknowledgements-We
are most grateful to Drs Carlos
Leon and Haydee Seijas for their assistance
in
preparing
the research proposal and to the laller especially
for
advice
and comments on our results. Drs Jairo Ortiz and Fer
nando Villanueva when students at the Universidad del
Valle. Cali, were an invaluable part or the biomedical team.
Much help was generously given
by
doctors and others
in the Putumayo medical services, and by the Sibundoy.
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