RETHINKING
THE CLASSIFICATIONS OF MEDICINES: A PROPOSAL FOR INTERCULTURAL CONTEXTS
Repensando la
clasificación de medicinas: Una propuesta para contextos interculturales.
†Anatilde Idoyaga Molina
Nota de las
Editoras
Anatilde Idoyaga Molina (1950-2020)
se desempeñó como Directora del Centro Argentino de Etnología Americana,
organismo dependiente del Consejo Nacional de Investigaciones Científicas y
Técnicas de Argentina. Recibió el cargo de Investigadora Superior de esa entidad
científica como corolario de su extensa y prolífera trayectoria académica.
Scripta Ethnologica
Nueva Epoca publica el presente artículo
inédito, que refleja cabalmente los aportes innovativos del pensamiento de
Idoyaga Molina en torno al fenómeno de la atención de la salud en contextos
interculturales. El mismo aborda un tema de plena vigencia en tiempos del pluriverso y de resistencias a la inteligibilidad
dominante. Con la claridad y agudeza teórica que caracterizaron su extensa
obra, la autora nos ha legado un texto de consulta obligada que resume sus
reflexiones y pensamientos, haciendo foco en la clasificación de medicinas a
partir del debate teórico con otros autores y de los resultados de su labor
etnográfica.
Abstract:
The article, firstly, deals with some definitions and
classifications of medicines generated in the social science and biomedical fields.
Then, the author proposes a systematization of medicines, incorporating new
categories, as well as the notion of ethno-medical configuration, to explain
healthcare in intercultural contexts. The categories introduced are biomedicine,
traditional medicine, alternative medicine, religious therapy or medicine, and
lay-treatment. Finally, as an illustrative example, the paper focuses on the
ethno-medical configuration of the Metropolitan Area of Buenos Aires, Argentina.
The goal of this systematization is proposing categories that consider the understandings
and behaviors of social actors.
Key
Words: ethnomedical configuration;
medicine’s categorizations; intercultural context; Argentina
Resumen: En primer lugar, el artículo aborda algunas definiciones y
clasificaciones de medicinas propuestas en el campo de las ciencias sociales y
de la biomedicina. Luego, la autora propone una sistematización de las
medicinas, incorporando nuevas categorías, así como la noción de configuración etnomédica, que le permite explicar la atención de la salud
en contextos interculturales. Las categorías introducidas son biomedicina,
medicina tradicional, medicina alternativa, terapia o medicina religiosa y
tratamiento no profesional. Finalmente, a modo de ejemplo ilustrativo, el
artículo se centra en la configuración etnomédica del
Área Metropolitana de Buenos Aires, Argentina. El objetivo de esta
sistematización es proponer categorías que consideren las comprensiones y comportamientos
de los actores sociales.
Palabras clave: configuración etnomédica;
categorizaciones de la medicina; contexto intercultural; Argentina
Introduction
Over the last decades, the combination of biomedicines with other (non-bio)
medicines has been studied in third world societies and developed countries
alike (Albuquerque, 1979; Atkinson, 1979; Bombardieri and Easthope, 2000; Csordas
and Kleinman, 1996; Douglas, 1996; Eisemberg et al.,
1993; Good 1987; Idoyaga Molina, 1999; 2000; Last
1996; Leslie, 1980; Saizar, 2003; Sermeus,
1987; Thomas et al. 1991; Unschuld, 1980; Vincent and Furnham, 1998; WHO,
2002). As a result, numerous concepts have been proposed, such as medical
pluralism, medical systems, medical configurations, and local, regional, and
cosmopolitan medicines, among others. Different conceptualizations of medicines
have emerged, such as professional medicine, folk medicine, popular medicine,
dominant and variant medicines, traditional medicine, complementary-alternative
medicine, and others.
In
this article, I propose a new classification of medicines, introducing the
concept of ethno-medical configurations to understand healthcare in
intercultural contexts. I discuss some classifications put forth by social and
biomedical scientists, evaluating their advantages and disadvantages. Then, I
present a classification, introducing the categories of biomedicine,
traditional medicine, alternative medicine, religious medicine, and lay-treatments.
I justify the categories used, underlining why it is relevant in any
multiethnic and multicultural context. I dwell on making clear the basis for the
religious medicine category. Finally, I give a short example to show the ways
in which those categories function, focusing on the ethno-medical configuration
of the Metropolitan Area of Buenos Aires City, Argentina. The goal of this
system is to propose categories which consider the understandings and behaviors
of social actors.
These
results are part of four research projects, funded by the Ministerio
de Ciencia, Tecnología e Innovación Productiva (Ministry
of Science, Technology and Productive Innovation) of Argentina, carried out from
1997 to 2010, focused on therapeutic complementariness and articulating
cultural, ethnic, socioeconomic, and religious identity as grounds for the selection
and combination of medicines. I also considered regional differences.
Pluralistic health offers and the
classifications of medicines
Social
scientists’ classifications usually propose few and general categories while
biomedical lists present more categories and sometimes focus on therapies in
isolation from the medicines that involve them. Therefore, one medicine may
appear in several therapy categories. In
the social sciences, some classifications seem to be ethnocentric, e.g. Wardell
(1972), because the definitions of the specialists and conceptions of health
and sickness are referred to and legitimated -or not- by the biomedical model. In
other cases, the criteria used are not completely justified, as in Dunn´s
classification (1977), which seems to be based on geographical factors, but
then incorporates additional perspectives. Kleinman (1980: 50) introduces
the concept of a “model of health care”, defined as “...a local cultural system
composed of three overlapping parts: the popular, professional, and folk
sectors”. Popular medicine contains several layers, including individual,
family, and social networks, as well as community beliefs and activities. It is
the lay-practiced, non-professional, non-specialist arena, where most episodes
of illness are managed. The professional sector comprises the organized health
professions. In most societies, this is modern biomedicine. However, in India
or China, professional medicine also entails Ayurvedic medicine, and Chinese
traditional medicine respectively (Kleinman, 1980: 51-2). The folk sector integrates
non-professional and non-bureaucratic specialists and tends to overlap the two
other sectors. It is a mixture of different components, some of them closely
related to the professional sector, and most linked to the popular sector because
the specialists and the common people share the same cultural background (Kleinman,
1980:59). In Taiwan, for example, the folk sector includes shamans, fortune
tellers, interpreters of the I ching divination
system, and geomancers.
Kleinman’s
proposal may be adequate for cultural and local systems; however, it would be
difficult to apply in the intercultural context of the Metropolitan Area of Buenos
Aires city, particularly because of the category of folk medicine. In Buenos
Aires, folk medicine comprises traditional healers of Western tradition;
specialists in yoga, acupuncture, reflexology, astrology, and natural medicine;
Catholic priests; and even shaman of the aboriginal groups of Argentina. Among
these specialists, whose social statuses and roles in society are diverse,
there are great differences in cultural beliefs and practices of health,
illness, and therapy. The offerings of these medicines run through different
social, economic, cultural, and ethnic sectors. They do not integrate a system,
in which all the parts are interrelated. The three categories seem to be too
few to differentiate the incidence of cultural, social, economic, ethnic, and religious
factors, with regards to the concrete therapeutic access, selections,
combinations, and rejections of the medicines offered.
Shifting
the perspective and focusing on population dynamics, ethnic and cultural
diversity runs counter to the concept of healthcare as a closed system. In the
Buenos Aires Metropolitan Area, the population is mostly
European-Argentines, Middle Eastern-Argentines, and Jewish-Argentines along
with immigrants from other South American countries (mainly Peru, Bolivia, and
Paraguay), immigrants from the Southeast Asia (mainly from China), immigrants from
the East Africa (mainly from Senegal), and some Native Peoples (migrants from
North Eastern Argentina). Each group has its therapeutic preferences, its own
traditional healers, lacks accesses to certain offers, and lacks knowledge and
interest of certain possibilities. Consequently, this conglomerate does not
function as a system.
It was Press, who criticized the use of
the system concept with reference to the mere presence of the diverse elements
within society, even if these elements all serve only one institutional sector,
due to the notion that a system is a functionally integrated entity with intercommunicating
parts (1980:46). For that reason, the author speaks of configuration, which integrates different medicines, classified as
dominant or variant. He also redefines the notions of folk and popular medicines.
According to Press, folk medicine should be limited to describing systems or
practices based upon paradigms which differ from those of a dominant medical
system of the same community (1980: 48). Per this
definition, autochthonous medical systems, such as Ayurveda, Chinese medicine,
Yanomamo, Bushman, or pre-contact Navajo, cannot be labelled as folk; instead, they
must be considered as dominant medicines, and biomedicine may be labelled folk
in certain contexts. Regarding popular medicine, the author suggests using the
concept in two ways. The first closely
approximates common usage by labelling all medical practices performed by someone
other than an officially sanctioned professional as popular and does not
directly contradict the paradigm of the system. A second usage would label only
those beliefs and practices which, though compatible with the underlying
paradigm of a medical system, are materially and behaviorally divergent from
official medical practice as “popular” (1980:48-49). Bearing in mind, these definitions,
Press examines the peasant Zinacatecan (México)
configuration and produces seven categories (1980:50). This classification is
exhaustive but complicates comparisons. Besides, in an intercultural context,
all medicines may be dominant, depending on which group or sector of the
population is considered.
Good
(1987: 23-24) introduced the concept of an “ethnomedical system”, defined as
the total medical recourses available to and utilized by a society, including
popular, traditional, and biomedical forms of therapy. Popular refers to lay-practices
and incorporates different levels of action, such as individual-based, family-based,
social-nexus-based, and community-based, following Kleinman’s suggestion.
Traditional medicines are those offered by a socially recognized specialist,
whose practices and knowledge change from society to society.
I
suggest the usefulness of the ethnomedical concept, which includes biomedicine without
favoring a priori the role of any medicine. At the same time, I follow the same observations previously completed.
Three categories are not sufficient to explain the perspective of specialists
and users, nor the influence of regional and global factors in local contexts. A
yoga specialist and a charismatic priest perceive insurmountable differences
between themselves. Similarly, a yoga consultant may not be interested in
charismatic healing or in consulting a traditional therapist. A user of
traditional medicine would hardly say that charismatic healing and yoga involve
the same kind of awareness and practices as their methods.
Keeping
in mind medical diversity in Europe, Pascualino
(1996:166) classifies medicines into three groups: a) traditional medicines, b)
ethnic medicines imported by recent immigrants, -mostly African peoples- and c)
new alternative medicines, linked to globalization and mass-media propaganda. I
agree with the distinction between traditional medicine and alternative medicines.
Nevertheless, the classification puts aside the therapeutic rituals, offered in
the context of the Catholic and Evangelical Church, and introduces a new
category to designate traditional medicines brought by immigrants, which are
essentially as traditional as the specifically Spanish or Italian ones.
The
World Health Organization recognizes distinct traditional medicines and
complementary/alternative medicines (CAM). Traditional medicines include “...traditional
Chinese medicine, Indian Ayurveda, and Arabic unani
medicine, and various forms of indigenous medicine” (2002: 1). In countries
where allopathic medicine is dominant, or where traditional medicine has not
been incorporated into the national health care systems, traditional medicines
are often designated as complementary or alternative medicines (ibid).
Usually, medicines are complementary when the treatment is undertaken
simultaneously with biomedical attendance, while medicines are alternative when
they replace biomedical treatment, or when they are the only medicine utilized.
The
WHO’s approach presupposes that, in the third world, health care is restricted to
biomedicine or traditional medicine, while in developed societies
complementary/alternative medicines are combined with biomedicine. This view is
limited because traditional medicines—in the sense of original medicines from
any given country—and alternative ones—meaning traditional medicines from foreign
countries—are simultaneously offered in developed and undeveloped countries,
and the therapeutic strategies of patients, at least in Argentina, combine these
two types of medicines (Idoyaga Molina, 2002a: 283).
This is equally observable in Spain and Italy. Finally, the combination with
biomedicine is not the only possible arrangement as medical combinations can
exclude biomedicine. Consequently, the notion of CAM seems to be ethnocentric,
and distorts the concept of therapeutic complementariness.
In
the United States, the National Center for Complementary and Alternative
Medicine, defines complementary treatments as those accepted by biomedicine and
alternative treatments as those not accepted by biomedicine, a categorization like
“conventional” medicine and “unconventional” medicine. This classification has
deserved its critics (Ayers and Kronenfeld, 2010); however, I emphasize new
perspectives. The Center distinguishes various types of CAM: a) natural
products such as herbs and dietary supplements; b) mind and body medicine such
as meditation, yoga, acupuncture, and hypnotherapy; c) manipulative and body
based practices such as chiropractic and massage therapy; d) movement therapies such as Pilates and Tragger psychophysical integration; e) traditional healers
who use methods based on indigenous theories, beliefs, and experiences handed
down from generation to generation; f) energy healing such as magnet therapy, qi
gong, reiki and healing touch; and g) whole medical systems such as biomedicine,
Ayurveda medicine, Chinese traditional medicine, homeopathy, and
naturopathy.
This
classification lacks usefulness because the categories are not mutually
exclusive and respond to several and not contrastive criteria. It also omits
the holistic view of most of the practices mentioned that
involve health conceptions and practices—for instance yoga—to a technique
removed from the context in which it acquires meaning—for instance meditation. Yoga
might be incorporated into almost all of the categories proposed because it a)
implicitly promotes a diet that can be considered a natural products therapy,
b) is included in mind body therapies, c) includes exercises known as asanas can be a movement therapy, d)
manipulates energy through breath and relaxation and can therefore be an energy
therapy, and d) could be considered a whole medical system, if we accept that
this type of system may be deeply rooted in philosophical and cosmological
beliefs.
The
biomedical categories of medicines and therapies are further complicated by
introducing categories of different range, and sometimes without any
specification, for instance on Barnes, Bloom, and Nahin´s list of therapies
appears yoga and meditation, without any clarification of what kind of
meditation -yoga, Zen Buddhist, Catholic- is practiced by the patient (2008:
2-3).
Ethnomedical Configuration
I understand healthcare as an ethno-medical configuration, referring to
the total recourses available, offered and used in any intercultural context (a
city, a region, etc.) (1). I accept the social actors’ points of view as
therapeutic and related to healthcare. It does not matter if they mention
consulting a biomedical doctor, or attending a therapeutic ritual, or avoiding
a taboo. I prefer to speak of configuration, showing Press’s influence. I
borrow Charles Good’s ethno-medical expression, underlining that biomedicine is
just one approach. Finally, I take Kleinman´s concept of healthcare as an
overlap of medicines. Bearing intercultural contexts in mind, I consider healthcare
to be the overlap of biomedicine, lay-treatments, and traditional, religious,
and alternatives medicines. I refer to lay-treatments to stress that each type
of medicine, and even each medicine, can generate its own practices of
lay-treatment.
Biomedicine
refers to allopathic medicine and psychotherapies: officially recognized and
offered in hospitals and other health units, both public and private. This
category, in one way or another, is referred to and appears in most
classifications, as professional, cosmopolitan, biomedicine, and so on.
Consequently, it is not necessary to extensively justify its inclusion.
Traditional
medicines vary from region to region, and societies recognize them as part of
their culture. In Argentina, these are curanderismo
(folk healings), brought by Europeans and other immigrants, as well as by shamans
in native indigenous societies. Curanderismo
or is widespread in Latin America
and traditional in many Mediterranean countries. Shamanic institutions are
traditional medical systems scattered throughout the indigenous societies of the
Americas, Australia, Sub-Saharan Africa, North and South Asia, and Indonesia. In
Argentina, shamans are the therapists among indigenous societies from Gran
Chaco to Misiones to Patagonia.
Alternative
medicines are not traditional in the country and do not integrate the
biomedical paradigm. Widespread in the last few decades, alternative medicines
are more or less associated to new age phenomena, but not linked to the
immigration of people. It might be said that the alternatives have migrated on
their own, disconnected from social actors.
The
category of alternative medicines makes it possible to distinguish the traditional
medicines of any society from those recently popularized, such as yoga,
acupuncture, reiki, and the like. Some alternatives have oriental origin, and
are really traditional, as in the case of acupuncture, or yoga; others are more
modern, such as reiki and shiatsu. Others are of Western origin, such as
homeopathy and naturopathy. Finally, it is convenient to use this category
because its services are mainly addressed to middle or upper classes because of
the relatively high cost of alternative therapies.
In
the past, a category of religious medicines would have been unthinkable. Separating
the medical sphere from the religious one is part of the cultural common vision
in Western secularized societies. In this frame, Dunn suggested that medical
systems must include only deliberate behavior that affects health, without
involving incidental behaviors with latent health functions (1977: 141). Thus,
totemic taboos, ritual activities, and other customs are not medical behaviors.
Medical behaviors may consist of all activities and considerations bearing on
the effect of disease, but it is possible to argue that any behavior could, at
some level, have some effect on health maintenance or susceptibility to disease
(Press 1980: 46).
Without creating a category of religious medicine,
various authors have stressed the role of religious healing and ritual
therapies. McGuire underlines that ritual healing extends into
middle-class communities (1998: 9-10). In a case study of suburban communities
in New Jersey, USA, McGuire proposes the following categories of ritual
healing: a) healing in Christian groups, b) traditional metaphysical movements,
c) Eastern meditation and human potential groups, d) psychic and occult
healing, e) manipulation /technique practitioners (1988: 18).
Blair
O’Connor noted that religious traditions have historically been closely
associated with healing practices in societies around the world (1995: 15-6).
In fact, myth and religion include the ultimate explanations and meanings
regarding serious illnesses and death.
Csordas
and Kleinman (1996) claim that religious healing is a generalized tool in
health care. They argue that religious healing appears just as frequently
in traditional as in complex societies. Religious healing has to do with diverse
practices from shamanism to movements of faith healing. Field (2001) stressed that
health and well-being conceptions—and their therapeutic side effects—and other
procedures are part of the Buddhism, Jainism, and Tantric goals and worldviews.
Numerous
behaviors overlap in the medical and religious spheres. The search for ritual
therapies, the performance of other religious practices, and the manipulation
of sacred symbols, in order to prevent and treat illness, are conscious and
growing actions in varied contexts, from shamanistic practices to Catholic
charismatic and Pentecostal healings to Oriental therapeutic rituals.
Privileging
the social actors’ point of view abandons the reductionist vision of knowledge and
practices of other societies and cultures based on ethnocentric prejudices and works
to understand the complexity of illness and health experienced vividly by human
beings.
The
proposal of religious medicines (or therapies) as a category does not
attempt to deny the manipulation of the sacred or the mythical-religious
aspects and rituals that may be corroborated in traditional medicines. If
religion is understood in terms of experience or encounters with the sacred, it
is true that the majority of “nonconventional” medicines may involve certain religious
beliefs and practices. In that case, it might be objected that the category of
religious medicine becomes diluted or that it lacks of precision. Nonetheless, it gains sense when limiting the
religious medicines category to the health offerings and treatments of illness
and affliction carried out in the contexts of the Churches that Weber called
institutionalized religions. I refer more specifically to the treatments
offered through ritual therapies performed in the contexts of Catholicism, Evangelism,
Pentecostalism, Judaism and Islam, which possess their own unique characteristics.
In institutionalized religions, liturgies clearly define who can heal and who
cannot, and which are the ways that become channels of the God to heal or solve
other types of misfortunes. In other words, it is established who may be endowed
with healing charisma. Significantly, these religions appear mostly in secularized
societies, unlike the cases of native shamanism or medicines in Oriental societies
where traditionally cosmologic-religious conceptions permeate all spheres of existence.
The
religions mentioned are a part of the same cultural background, therefore their
rituals and beliefs have deep links and likenesses based on the Bible. These
religions have their own specialists, who serve a similar role to shamans and
other therapists in the cases of other medicines. Their therapeutic ritual and religious
healing activities are easily identified and can be contrasted with any other
kind of religious healing performed in any local or regional medical care. The
universal nature of Christianity turned these religious therapies into
ecumenical offers and, even considering the syncretic processes that these practices
have generated, the category of religious medicine permits distinguishing
Christian ritual therapy from other ritual therapies in any part of the world. Given
the universalistic nature of Christianity, it is a generalized therapeutic
offering which spread throughout the world via the missionary. It is not a therapeutic
offering limited by geography, only available or viable in countries of Western
and Christian tradition. Religious offering are
therapeutic from the social actors’ point of view. Consequently, based on
phenomenological insight, this category is theoretically and methodologically supported.
Finally, this category facilitates the observation and description statistically
significant differences in treatment (Idoyaga Molina
and Luxardo, 2005) (2).
We
could also add to this category the ritual therapeutic practices which have arisen
through the synthesis of Christian or Muslim traditions with other cultural
beliefs, such as the Churches known as Afro-Argentine in which Christian
conceptions are evident. Similar seems to be Rasanayagam´s
asseverations (2006- 378-81) about the syncretism in relation to Muslim
Churches in Uzbekistan. Nowadays the states attempt to monopolize the answer to
the question of what it means to be a Muslim. Some of the local practices
tolerated by the government would be considered heterodox by followers of a scripturalist
interpretation of Islam. Such practices involve healing with the aid of spirits
and a variety of new age healing ideas.
In
summary, I understand religious medicines as beliefs, notions, and practices
carried out in the context of ceremonies, services, rituals, and other
activities addressed to the corporal and spiritual healing of the petitioners,
that are supported by the beliefs, conceptions, and cosmologies of the mentioned
religions.
In
the case of Catholicism, activities are carried out both within the
institutional religious contexts and by specialists who are not officially
recognized (Viturro, 1998:133). Therapeutic actions include
healings during the cults’ services or in private consultations and asking
clerics for prayers in the name of a sick person (this may even be done by
phone to closed order nuns, such as the Barefoot Carmelites). Some healing
techniques are the blessing, healing touch, prayers, contact with the tabernacle,
and exorcisms. Broadly speaking, practices of the different Pentecostal and
Evangelical churches are like each other and, at the same time, to those of
Catholicism. Individual and collective prayer, reading of the Bible in search
of explanations, healing touch, exorcism, invocation of the Holy Spirit, and
trances are common practices. The latter allows the individual access to a
numinous experience and direct interaction with the Deity.
In
Judaism several trends exist; it is generally recognized that some rabbis,
though not all, have the power to cure and carry out other transforming
actions. They are usually known as tsaddik,
implying that they are wise men. In the Hasidic congregation, those leaders
having the charisma are called rebe. Healing techniques include prayer, the repetition of
formulas, and, less frequently, the healing touch.
Among
Muslims, there are specific priests or imams who engage in healing more
frequently. They also resort to prayer, to blessings, and to repeating formulas
and spells that are sometimes accompanied by gestures indicating the rejection
of illness.
Among
Muslims and Jews, accesses to therapeutic rituals are limited to the persons
really engaged with the Church activities and beliefs. In contrast, Catholics,
Pentecostals, and Evangelical, admit into their cults any kind of people—it
might even be said that the experience of being cured is a way of recruiting
new believers.
Lay-treatment,
also called popular medicine, is a more complex category than it seems. Referring
to popular medicine, authors have emphasized its connection to popular culture
as a whole (Kleinman 1980: 50) and recognized that there may be more than a
singular popular medicine. Press (1980: 50) suggests at least two types—biomedical
popular medicine and Zinacatecan popular medicine—and
would surely accept the existence of more popular medicines in any
intercultural context, minimally, as many popular medicines as there are ethnic
groups. Nevertheless, this does not exhaust the types of lay treatments that may
appear in any society where alternative medicines have spread. These
alternatives also generate their own lay practices. For instance, any of the
yoga techniques—breathing, meditation, asanas,
etc.—may be performed individually
with therapeutic goals; the same could be said with respect to mental control, reiki,
and so on. Regarding religious therapeutic rituals, the prayer group shows the lay
treatments in the context of Catholicism, as well as praying novenas, making
promises to saints or virgins, participating in healing missal, and so on. It
means that lay-treatments derive from more than a singular coherent culture and
implies that many kinds of lay-treatments are present in a particular context,
and that these different types of lay-treatments may respond to different cultural
beliefs and behaviors. There is not only one popular culture framing the
lay-treatments, and these cultures are not necessarily closer to traditional
medicines than others, even if they might be closer to biomedicine. Of course,
lay-treatments involve individual, familiar, social, and community levels of
practices. I prefer the term lay-treatment to popular medicine because in
Spanish, the expression popular medicine is often used as a synonym of traditional
medicine. Therefore, it is not associated with lay practices.
Lay-treatments
are varied. Biomedical lay treatment implies the consumption of unrestricted
laboratory medication and psychotropic remedies, among other possibilities,
without medical prescription. Traditional lay-treatment or domestic medicine shares
the paradigm of the traditional healers or curanderos,
including home vernacular remedies such as plasters, infusions, baths, and
certain therapeutic rituals of catholic roots, such as healing formulas. Alternative
lay treatments entail the use of techniques learned and derived from
alternative medicines, such as relaxation or mental control procedures,
hydrotherapy practices, and consuming natural remedies. Religious
lay-treatments include prayer groups, novenas, promises, healing touch
practiced by a non-specialist, praying, collective healing rituals, and so on.
This
proposal explains healthcare through the overlapping of biomedicine,
traditional medicine, religious medicine, alternative medicine, and lay-treatments.
Cultural, socioeconomic, and ethnic differences determine if the number of
overlapping medicines includes all of these offerings or only some of them.
These
categories allow distinguishing: a) traditional medicines from any country from
the alternative medicines, spread in the last decades; and b) traditional
healers from lay healers with some popular expertise, who have been confused by
some Argentine and Latin American authors because their likenesses in relation to
the use of cataplasms, cupping, several remedies of a vegetal origin, and
therapeutic rituals of catholic roots. The category of religious medicines
that, owing to their specificity and connection with some religions, is
not convenient to include in the alternative medicines, as certain authors do
under the category of spiritual therapies (Eisemberg et
al., 1993: 247; Franco and Pecci, 2003: 112).
The ethno-medical configuration in
the Metropolitan Area of Buenos Aires
In order to show the usefulness of the proposed categories, I give a
short example based on ethnographic data. Biomedicine is the legal practice in
Argentina. Public biomedical and psychotherapeutic services are universal and
free to the entire population through hospitals and less complex units called health
centers since the beginning of the 20th century. These services guarantee
biomedical attention to low-income people, as well as marginal and immigrant
populations. Individuals of the middle and upper classes usually access private
health services, which facilitate more efficient and less bureaucratic care,
though it depends on the cost, the quality, and the services offered. The more
expensive options permit the client to select the professionals out of the list
of options given by the insurance company and recognize specialties that are
not available in public units, such as homeopathy.
The
traditional medicines are shamanisms and curanderismo
(folk healing). The latter is more widespread and is common in both rural
and urban areas. Broadly speaking, traditional healers’ or curanderos´ notions and practices synthesize ancient biomedical
knowledge—many of humoral medicine origin—with European folk medical traditions
and therapeutic rituals, mostly of Catholic roots (Idoyaga
Molina, 1999/2000: 260; 2008: 69; Idoyaga Molina and Sarudianky, 2011: 316). This is not to deny the dynamics of
history, as traditional healers incorporate and reconfigure several elements,
types of services, and knowledge, allowing them to adapt to the new local and
global contexts.
Shamanisms
are the traditional medicines of the natives of Great Chaco, Misiones, and
Patagonia. These shamanisms are very different institutions and underwent different
changes due to their contact situation with white colonists (Turner, 1988). Toba
and Pilaga natives, who migrated from the Gran Chaco
to the Metropolitan Area, brought their shamanistic practices with them, which
are offered only to natives.
In
Argentina, religious healings are usual practiced in the services and other
activities of Evangelist, Pentecostal, Catholic, Jewish, and Muslim groups. The
Pentecostal and Evangelical Churches got believers mainly from the lower
classes, though, recently, they have reached all social classes. Religious identity
is a basic tool when selecting or deciding upon a combination of therapies;
following the advice of their pastors, believers reject the traditional healing,
Afro- Argentine cults, Catholic practices, and any other religious healings outside
of their own Church (Idoyaga Molina, 1999: 23).
The
impact of the charismatic and other catholic groups may be noted in the entire
population regardless of socioeconomic factors and levels of education (Funes, 2008: 8; Idoyaga Molina,
1999: 24). Afro-Argentine cults are widespread in Buenos Aires, having
recruited individuals mostly from the lower classes (Frigerio and Carrozzi, 1992:40).
However, their services—cleansings, predictions, and sorcery—are utilized by
individuals of all socioeconomic levels, including the upper class. In
contrast, Jewish and Muslim ritual-therapeutic practices are not open to the
public; instead, they are an option only for those individuals committed to the
religious groups.
The
alternative medicines offered include yoga, reiki, reflexology, Ayurvedic
medicine or Indian humoral medicine, aromatherapy, chromo-therapy, gem-therapy,
acupuncture, tai-chi-chuan, neo-shamanism, massage-therapy, Zen meditation, Chinese
traditional medicine—incorporating Chinese humoral medicine—healing touch,
shiatsu, digit-puncture, astrology, natural medicine, and qi gong, among many others.
Alternative medicines are usually expensive, available only in urban contexts,
and target middle- and upper-class sectors. The most accepted is yoga, followed
by reiki, reflexology, acupuncture, and shiatsu.
These
aspects place alternative medicines out of the possibilities of the lower classes.
Nevertheless, there are cheap and even free offers, especially of yoga, in
Parish and neighborhood clubs and accessible options of shiatsu, reiki, and
reflexology (Saizar, 2009: 24-27; Pitluk,
2006: 38). Even some hospitals in Buenos Aires offer free of yoga, reiki, qi
gong, reflexology, meditation, Tibetan therapeutic music, tai-chi-chuan, and
other workshops under the guise of activities to improve quality of life (Saizar
and Korman, 2012: 4). From the professionals´ perspectives, yoga is recommended
to patients suffering from anxiety or depression (Korman 2010: 69).
Other
alternatives are less popular, like neo-shamanism, which is usually experienced
by people with long trajectories in this type of therapy (Idoyaga
Molina, 1997 b: 430).
To
consider the strategies of therapeutic complementariness in the Metropolitan
Area linked to culturally homogeneous units, I must distinguish among various
groups: a) culturally conservative popular sectors mainly composed of European-Argentines
and Middle East-Argentines; b) culturally modern middle and upper classes
mainly composed of European-Argentines and Middle East-Argentines; c) culturally
native aboriginal immigrants from Gran Chaco; d) culturally westernized and
conservative immigrants from neighbouring countries,
mostly mestizo; and e) recent immigrants from African and Asian countries.
The
first group attends to their health mainly by overlapping traditional lay-treatment,
biomedicine, and curanderismo. The latter involves consuming remedies
usually classified in hot and cold categories, fumigating, and many therapeutic
rituals, some of them associated with particular folk illnesses—calling the
soul back, putting the baby inside a just dying cow, diagnosing with oil and
water—and others used to heal all kinds of sickness episodes—reciting the acute
spell, lighting saints and virgins, consuming blessed water (Idoyaga Molina, 2002b: 123-28). Religious medicines, such
as Catholic and Evangelical, and less frequently Afro-Argentine cults, may be
added if the illness episode is prolonged. Alternative medicines are rare and the
last option; among them the preferred is yoga (Idoyaga
Molina, 2000: 25-7; Idoyaga Molina and Krause,
2001/2: 211). Shamanism as an option is practically unknown.
Persons
from the middle and upper classes combine all the kinds of available medicine
and make appointments with specialists of any type of medicine. These
therapeutic pathways combine traditional medicine, religious medicine,
alternative medicine, biomedicine, and lay-treatments.
The
most common complementariness is among biomedicine, religious and alternative
medicines, and lay-treatments. Despite yoga being the preferred alternative
medicine, the variety and the frequency of medicines consulted and used is
relevant. Catholic therapeutic rituals are the most selected among religious
offerings due to its being the religion of most of the middle and upper classes.
In this arena, it is common participate in healing Mass, while the typical
therapeutic rituals are the healing touch and prayer. Less frequently, the
complementariness involves only biomedicine and alternative medicine or
biomedicine and religious practices. In only a few cases, patients add
traditional medicine to the combination of biomedicine, religious, and alternative
medicines, and shamanism is an unknown option. Finally, the most unusual
behavior is to reject any medicine other than biomedicine, or to combine
different medicines but avoid biomedicine.
Regarding
lay treatments, all of them are used, including biomedical remedies without
professional prescription. Participation in prayer groups is the most popular
option among religious lay-treatments (Idoyaga Molina
and Funes, 2011: 60), using healing spells, and
another techniques to treat the empacho
(blocked digestion) and headaches are popular among traditional lay-treatments (Idoyaga Molina and Sacristan Romero, 2008: 204-08), and a
variety of alternative medicine procedures, such as relaxation, meditation,
breathing, exercising (asana),
auto-administration of energy practicing reiki, shiatsu, gem-therapy, and so on
are used.
Toba
and Pilaga Indians, immigrants from the Central
Chaco, combine shamanism, biomedicine, the ritual-therapeutic practices of the
Pentecostal Indian, and native lay-treatment, which has incorporated some Western
traditional lay-treatment procedures because of the contact situation. In this context, therapeutic plans may occasionally include consulting
a curandero or traditional healer,
and European-Argentines and mestizos may visit a shaman (Martínez, 2007:215).
The
strategies of immigrants of neighboring countries are similar; they mainly
combine biomedicine, curanderismo or
traditional medicine, traditional lay-treatment, and natural medicine or
naturopathy lay-treatment, the last also being rooted in humoral medicine (Idoyaga Molina et al., 2003:174). Occasionally, some of
them practice yoga through the hospital´s free offers. Finally, some of them
are Evangelical believers who consequently reject traditional medicine, which
is substituted by therapeutic rituals of their own Church. Those who identify
as Catholics may add to the aforementioned medicines some Catholic therapeutic
rituals.
African
immigrants combine their own lay-treatments, biomedicine, and sometimes their
own traditional medicines when they can. Others reject traditional medicine
because they converted to Islam.
Chinese
immigrants combine their own lay-treatments, biomedicine, and Chinese
traditional medicines, especially those available in the Chinese neighborhoods,
where the specialists are Chinese natives.
The
perspective sustained tries to make it easier to distinguish differences among
social classes, cultural, and ethnic groups. If I had used just three
categories -professional, folk (or traditional), and popular-, it would have
seemed that all the population of the Metropolitan Area of Buenos Aires access
and combine the same medicines over and beyond biomedicine, which is not true.
Conclusions
Therapeutic complementariness strategies have increased over the last
decades and include individuals from all social and economic classes, all
education levels, and from different ethnicities and cultures. Therapeutic
complementariness is probably a universal strategy in healthcare, leading researchers
to classify medicines and to generate concepts that embrace all types of healthcare
combinations. The classifications proposed by social scientists based on
ethnographic work and those proposed in the biomedical fields are essentially
divergent. Despite the desire to reach a
consensus about healthcare classifications, one has yet to be found.
The
classification presented herein is an attempt to make some clarifications of
the possible limits of the three well-established categories of medicine by
analyzing intercultural contexts. At the same time, a greater number of
categories is necessary where multiethnic and multicultural populations coexist
and try to solve their health problems in conglomerates, informed by various
social actors’ points of view. The lay treatments seem to be larger than the
popular medicine associated with a popular culture would suggest. Further, I want
to call attention to the uncritical use of some categories, just because the
user referred to such expression—as meditation—without considering the wider
frame of meaning in which the practice takes place.
Notes
(1) This classification was first drafted
as an ethno-medical system in Idoyaga Molina (1997a).
(2)
Alternative medicines are more widely used by individuals from the middle and
upper classes than by individuals from the lower class, whereas religious medicines
are longitudinal and are frequently used by all classes. Consequently, if we
add religious therapies to a category of spiritual healing listed among
alternative, the prevalence of class difference disappears. In Rigor we did not have a category of spiritual healing, but
we could consider in its place Zen Buddhist meditation—which was on our
alternatives list—to make clear what I am trying to explain. In other words, in
a sample of 200 patients suffering from cancer, 76% were treated with at least
one alternative, and 55 % were treated with at least one religious’ therapy (Idoyaga Molina and Luxardo, 2005:
391-92). If we add religious therapies to a category of spiritual healing
(Buddhist meditation) among the alternative medicines, it would increase the
percentage of alternatives used, and would increase the percentage of the
spiritual healing from 7% to 62%. The alternative percentage would increase
because not all the users of religious medicine had also used alternative
medicines.
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